Ac a elec onica Uni e si a is Lapponiensis 328
Mi a Alhonsuo
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Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
1
Ac a elec onica Uni e si a is Lapponiensis 328
MIRA ALHONSUO
Ea ly Phase o Heal hca e-Rela ed Se ice Design
Academic disse a ion o be publicly de ended wi h he pe mission
o he Facul y o A and Design a he Uni e si y o Lapland
in Esko ja Asko hall on 10 Decembe 2021 a 12 noon.
Ro aniemi 2021
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Copy igh license: CC BY-NC 4.0
Co e a : Ma a Ki ekäs
Layou : Mi a Alhonsuo
Ac a elec onica Uni e si a is Lapponiensis 328
ISBN 978-952-337-296-2
ISSN 1796-6310
Pe manen add ess o he publica ion: h p://u n. i/URN:ISBN:978-952-337-296-2
Uni e si y o Lapland
Facul y o A and Design
Supe ised by
P o esso Sa u Mie inen, Uni e si y o Lapland
Doc o Melanie Sa an ou, Uni e si y o Lapland
Eme i a P o esso Kaa ina Mää ä, Uni e si y o Lapland
Re iewed by
Doc o and Lead Se ice Designe Ki sikka Vaajakallio, Hellon Se ice Design Agency
Ka ja Ba a bee, Doc o o A s, Apple
Opponen
Doc o and Lead Se ice Designe Ki sikka Vaajakallio, Hellon Se ice Design Agency
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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Abs ac Abs ac
Heal hca e o ganiza ions a e unde cons an p essu e o de elop and
e o m. The objec o be de eloped may a y om he hospi al’s signs
o na ional social and heal hca e e o ms. Se ice design and co-design
p o ide one way o esea ch and de elop heal hca e se ices. These
di e en ways o app oaching de elopmen can suppo and inspi e people
o pa icipa e in he de elopmen p ocess.
This esea ch ocused on examining he ea ly phase o heal hca e-
ela ed se ice design and de e mining wha is needed be o e s a ing
an ac ual design p ocess in a heal hca e o ganiza ion. The ocus was
na owed o looking a he pe spec i es o heal hca e p o essionals as
well as how hey can be in oduced o se ice design and co-design and,
hus, how o a ouse hei in e es in design-d i en de elopmen ac i i ies.
These pe spec i es gene a ed he main esea ch ques ion: How can se ice
design and co-design app oaches suppo he ea ly phase o heal hca e-
ela ed se ice de elopmen ?
This a icle-based esea ch is g ounded in cons uc i ism and
encompasses a quali a i e esea ch p ojec using case s udy and e hnog aphy
as he me hodological choices. The esea ch was ca ied ou h ough ou
sub-s udies, o mula ed as academic publica ions. Sub-s udy I in es iga ed
se ice design ools and collabo a i e p ac ices used o suppo and
de elop cus ome jou neys and hospi al managemen p ac ices. Sub-s udy
II aimed o unde s and how pa ien s’ expe iences and co-design me hods
we e used in he p e-cons uc ion phase o a new hospi al. Sub-s udies
III and IV we e conduc ed h ough h ee design sp in s and assessed, o
ins ance, he in ol emen o heal hca e p o essionals as pa o he design
sp in s and wha we e he s eng hs and weaknesses o he design sp in s,
especially in ela ion o he de elopmen o heal hca e se ices.
The indings om hese sub-s udies yielded he ollowing
conclusions. Fi s , benchma king is an impo an p ocess bo h o
de eloping hospi al managemen p ac ices and o selec ing e icien
design-based me hods du ing he de elopmen p ocess. Second, design
me hods a e a way o c ea e and sha e a ision, unde s and se ice

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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ecosys ems, conc e ize se ices, and ga he e idence o he bene i s o
se ice design and co-design. Thi d, he p essu ed imescale and limi ed
heal hca e esou ces challenge pa icipa ion in co-design and he usage
o design me hods. Las ly, he design sp in in heal hca e is an e icien
p ocess o knowledge and in o ma ion sha ing, unde s anding he
design p ocess, lea ning di e en design me hods, and c ea ing syne gy
among s akeholde s. Design sp in s can, he e o e, be seen as an in ensi e
in oduc ion o he se ice design ield and co-design.
The p inciple esul o his esea ch is a p ac ical amewo k o
he ea ly phase o heal hca e- ela ed se ice design – be o e he ac ual
de elopmen p ocess. The amewo k in oduces h ee main sub-phases:
benchma king, p epa a ion, and design sp in . The amewo k allows o
obse ing he di e en le els o se ice ecosys ems, cla i ying he ea ly
phase o heal hca e- ela ed se ice design, such as he dimensions o he
se ice o be de eloped and he esou ces needed du ing he de elopmen
p ocess, and discussing he design me hods sui able o e e yday wo k.
Keywo ds: se ice design, co-design, heal hca e se ice de elopmen ,
design p ocess, design sp in
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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Tii is elmäTii is elmä
Te eydenhuollon o ganisaa io o a ja ku ien uudis uspaineiden
alla. Kehi e ä än koh een mi asuh ee oi a aihdella sai aalan
opas auluis a al akunnallisiin sosiaali- ja e eydenhuollon uudis uksiin.
Pal elumuo oilu ja yh eissuunni elu a joa a yhden a an u kia ja
kehi ää e eydenhuollon pal elui a. Nämä e ilaise kehi ämisen a a
oi a ukea ja innos aa ihmisiä osallis umaan kehi ämisen p osessiin.
Väi öski jassa u ki iin e eydenhuollon pal eluiden kehi ämis-
p osessin alku aihe a e eydenhuollon o ganisaa iossa. Tu kimus
aja iin e i yises i e eydenhuollon amma ilais en näkökulmiin, sekä
siihen, millä a oin amma ilaise oidaan u us u aa pal elumuo oiluun
ja yh eissuunni eluun, ja mi en he ä e ään heidän kiinnos uksensa
muo oiluläh öiseen kehi ämis oimin aan. Täs ä läh ökohdas a syn yi
u kimuksen pääkysymys: mi en pal elumuo oilun ja yh eissuunni elun
lähes ymis a a oi a ukea e eydenhuol opal eluiden kehi ämisen
alku aihe a?
Väi öski ja on a ikkelipohjainen. Si ä ohjaa kons uk i is inen
pa adigma. Tu kimuss a egia on laadullinen, ja sen me odologisia alin oja
o a e nog a ia ja apaus u kimus. Väi ös u kimus on jae u a ikkeleiden
mukaan neljäksi osa u kimukseksi. Ensimmäisessä osa u kimuksessa
a kas el iin pal elumuo oilun yökaluja ja yh eissuunni elun apo-
ja sai aalan joh amiskäy än öjen ukemisessa ja kehi ämisessä.
Toisen osa u kimuksen a oi eena oli ymmä ää, mi en po ilaiden
kokemukse ja yh eissuunni elun mene elmä on o e u huomioon
sai aalan akennusp ojek in esisuunni elu aiheessa. Kolmannessa ja
neljännessä osa u kimuksessa o eu e iin kolme muo oilusp in iä.
Niiden kau a a kas el iin muun muassa e eydenhuollon amma -
ilais en osallisuu a osana muo oilusp in iä sekä si ä, mi kä o a
muo oilusp in ien ah uude ja heikkoude e i yises i e eydenhuollon
pal eluiden kehi ämisessä.
Näiden osa u kimus en kau a ki ey yi ä as aukse u ki-
muskysymyksiin. Tu kimus uloksina kye iin osoi amaan, e ä e -
ailuanalyysi, eli benchma king, on ä keä p osessi niin sai aalan
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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joh amiskäy än öjen kehi ämisessä kuin oimi ien muo oiluläh öis en
mene elmien alinnassa kehi ämisp osessin aikana. Muo oilun
mene elmä osoi au ui a a aksi luoda ja jakaa isioi a, ymmä ää
pal eluekosys eemejä, konk e isoida pal eluja ja ke ä ä odis ei a
pal elumuo oilun ja yh eissuunni elun hyödyis ä. Tulokse osoi a a ,
e ä aika aulupainee ja ajallise e eydenhuollon esu ssi hankaloi a a
yh eissuunni eluun osallis umis a ja muo oilun mene elmien käy öön-
o oa. Te eydenhuollon muo oilusp in ien a ulla oi iin edis ää iedon
jakamis a, muo oilup osessin ymmä ämis ä, e ilais en muo oilun
mene elmien oppimis a sekä sidos yhmien älisen syne gian aken amis a.
Muo oilusp in i oidaankin nähdä in ensii isenä johda uksena pal elu-
muo oiluun ja yh eissuunni eluun.
Tu kimuksen pää uloksena luo iin käy ännönläheinen ii ekehys
e eydenhuollon pal elumuo oilun alku aiheen ueksi – ennen i allisen
kehi ämisp osessin käynnis ämis ä. Vii ekehys muodos uu kolmes a
aihees a: e ailuanalyysi (benchma king), almis elu ja muo oilusp in i.
Vii ekehyksen a ulla oidaan a kas ella pal eluekosys eemien e i asoja
sekä si ä, mi en alku aiheen suunni elua oidaan selkey ää esime kiksi
a kas elemalla kehi e ä än pal elun mi asuh ei a ja kehi ämisp osessin
aikana a i a ia esu sseja sekä yöa keen so el u ia muo oilun
mene elmiä.
A ainsana : pal elumuo oilu, yh eissuunni elu, e eydenhuollon
pal eluiden kehi äminen, muo oilup osessi, muo oilusp in i
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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Acknowledgmen s Acknowledgmen s
This academic jou ney has plan ed li elong oo s ha keep me s anding
e en in a high wind. These oo s ha e g own s ong and long. I would
like o ake his oppo uni y o hank hose whose exis ence has been
signi ican on he jou ney and who, wi h hei own skills and essences,
ha e s eng hened my oo s. These wo ds a e he inal w i en ows in my
disse a ion bu a e de ini ely he mos impo an o me. Wi h a wa m
hea , I would like o hank he ollowing people.
I ha e been lucky o ha e h ee in elligen supe iso s, who a e
s ong and empa he ic women, o guide my disse a ion. Thank you,
P o esso Sa u Mie inen. You ha e suppo ed me om he beginning and
belie ed in me. You’ e gi en me enough eedom o ake my own pa h bu
ha e shown di ec ions whene e my compass hasn’ known which way o
poin . You ha e shown me places om which I ha e d awn expe iences
and c ea ed impo an ela ionships o he u u e. I am o e e g a e ul o
hese oppo uni ies and momen s oge he . Thank you, Eme i a P o esso
Kaa ina Mää ä. You came along in he inal s ages o my disse a ion
p ocess, when my head was ull o mo e o less uzzy ideas. You augh me
o hink mo e clea ly, o belie e in mysel , and o us ha my esea ch
was almos comple e, e en hough I s ill had a long way o go. You posi i e
essence has le me wi h good memo ies. Finally, he mos impo an and
signi ican woman on my esea ch jou ney is Adjunc P o esso Melanie
Sa an ou. I go o know you a he beginning o my pos g adua e s udies,
when I was looking o mysel and I was al eady changing di ec ion. You
poin ed me owa d he pa hs I could walk. You’ e been he e when I’ e
been los and b ough me o wa d. You ha e been a piece o gold on his
jou ney, and he e a e no enough wo ds o say how g a e ul I am o you.
Thank you, Melanie!
I had wo wonde ul indi iduals as p e-examine s o my disse a-
ion. Thank you, D . Ki sikka Vaajakallio, o you insigh ul hough s.
I el ha I had succeeded and g own mo e as a esea che . Thank you
o ag eeing o be my opponen — o sha e a discussion abou expe iences
ha ha e also been signi ican and impo an in you wo k. Thank you,
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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Figu e 14. Examples o a isualized se ice concep s c ea ed o amilies
and heal hca e p o essionals du ing he case-s udy 2 in sub-
s udy I. (Au ho ’s illus a ions)
Figu e 15. Design sp in p ocess in Go henbu g, Sweden.
Figu e 16. Design sp in p ocess in Tallinn, Es onia.
Figu e 17. Design sp in p ocess in Ro aniemi, Finland.
Figu e 18. Men o ing du ing he design sp in s in Ro aniemi. (Pic u es:
Maileena Tuokko)
Figu e 19. Facili a ion in he p ac ice in he design sp in in Ro aniemi.
In he pic u e on he le , I am nego ia ing wi h he coo dina o
om he hospi al. In he pic u e on he igh , I am lis ening
o and obse ing he design sp in eam membe s. (Pic u es:
Maileena Tuokko)
Figu e 20. O e iew o he p ac ical amewo k “P e-phase o heal hca e
se ice de elopmen ” as pa o he design p ocess o se ice
de elopmen . (Au ho ’s illus a ion)
Figu e 21. P e-phase o heal hca e se ice de elopmen amewo k and
he se ice ecosys em le els. (Au ho ’s illus a ion)
Figu e 22. Benchma king h ough se ice p o o yping in SINCO-lab,
Uni e si y o Lapland. (Pic u es: Maileena Tuokko)
Tables:
Table 1. Summa y o sub-s udy I.
Table 2. Summa y o sub-s udy II.
Table 3. Summa y o sub-s udy III.
Table 4. Summa y o sub-s udy IV.
Table 5. S eng hs and weaknesses om design sp in pa icipan s’
pe spec i es.
Table 6. Key indings om sub-s udy I.
Table 7. Key indings om sub-s udy II.
Table 8. Key esul s om sub-s udy III.
Table 9. Key indings om sub-s udy IV.
Table 10. The h ee s eps o p elimina y p epa a ions om he iewpoin
o objec i es.
Table 11. The h ee s eps o p elimina y p epa a ions om he iewpoin
o impac s and alue.
Table 12. The h ee s eps o p elimina y p epa a ions om he iewpoin
o design ools and me hods.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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Abs ac ..................................................................................................................4
Tii is elmä .............................................................................................................6
Acknowledgmen s ..............................................................................................8
Lis o O iginal Publica ions and he Au ho ’s Con ibu ions ...... 12
Lis o Figu es and Tables ............................................................................. 14
Table o Con en s ............................................................................................. 16
1. In oduc ion .............................................................................................19
1.1. Resea ch Focus and Con ex .............................................................19
1.2. My Resea ch Jou ney ..........................................................................24
1.3. Resea ch Ques ions and Aims ...........................................................27
1.4. Resea ch Limi a ions ..........................................................................29
1.5. S uc u e o he Disse a ion .............................................................30
2. Theo e ical Backg ound .......................................................................33
2.1. Se ice Design .....................................................................................33
2.1.1. Role o he Se ice Designe ...................................................37
2.1.2. Di e en P ocesses in Design and De elopmen .................40
2.1.3. In e play be ween Di e en Se ice Le els ...........................49
2.2. Co-design .............................................................................................53
2.3. Heal hca e Se ices .............................................................................56
2.3.1. Change in Heal hca e O ganiza ions .....................................57
2.3.2. Heal hca e De elopmen .........................................................60
3. Resea ch Design ......................................................................................65
3.1. Resea ch h ough Design ...................................................................65
3.2. Cons uc i ism ....................................................................................69
3.3. Resea ch S a egies and Me hodological Choices ..........................70
Table o Con en sTable o Con en s
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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16
3.4 Da a Collec ion Me hods and Analyses o he Sub-S udies ...........73
3.4.1. Sub-S udy I ................................................................................76
3.4.2. Sub-S udy II ...............................................................................83
3.4.3. Sub-S udies III and IV .............................................................83
3.5. E hical Conside a ions and E alua ions ..........................................89
3.6. Re lexi i y o he Resea ch .................................................................93
4. Resul s.........................................................................................................95
4.1. Se ice Design Tools as Suppo ing and De eloping
Hospi al Managemen P ac ices........................................................95
4.1.1. Benchma king as a P ocess o De elop
Hospi al Managemen P ac ices .............................................95
4.1.2. Design Me hods as a Way o C ea e and Sha e a
Vision and Unde s and Ecosys ems .......................................98
4.2. Pa ien s’ Expe iences o Heal hca e Se ices ..................................99
4.3. S eng hs and Weaknesses o Heal h-Rela ed Design Sp in s .....102
4.4. Heal hca e Rep esen a i es as Suppo ing Design Sp in s
in Heal hca e Se ices ......................................................................106
4.5. Summa y o he Key Findings .........................................................110
5. Discussion ...............................................................................................115
5.1. P elimina y P epa a ion and E idence ..........................................115
5.2. Familia iza ion wi h he Unknown ................................................118
5.3. P ac ical F amewo k o Heal hca e Se ice De elopmen ........120
5.3.1. P ac ical F amewo k and Se ice Ecosys em Le els ..........123
6. Conclusions ............................................................................................129
6.1. Impac s o he Resea ch ...................................................................129
6.2. Sugges ions o Fu he Resea ch ...................................................130
Re e ences .........................................................................................................133
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Pic u e: Maileena Tuokko
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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1. In oduc ion
1.1. Resea ch Focus and Con ex
Heal hca e is a complex ield o mul i-laye ed p ocesses, a ie ies o
ac ions, and people wi h di e en backg ounds and expe ise (Bowen e
al., 2013). As a se ice, i is uni e sally used and has an impac on ou
economies and quali y o li e (Be y & Bendapudi, 2007), and i ackles,
o ins ance, con inuing g ow h, he aging popula ion, se ice e o ms,
new echnologies, and abo e all, in e nal and ex e nal p essu es o change
(F y, 2019). These challenges push heal hca e owa d mo e inno a i e
solu ions, which o en migh be di icul o implemen no only due o
o ganiza ional esis ance o change (Vink, Joly, We e -Edman, T on oll,
& Ed a dsson, 2019; Wang, Lee, & Maciejewski, 2015) bu also a lack
o ocused and secu e managemen (F y, 2019; Nilsen, Dugs ad, Eide,
Gullsle , & Eide, 2016). These challenges can also be seen as “wicked
p oblems” ha a e di icul o impossible o sol e. Tha is, as he e a e no
unambiguous c i e ia o ag eemen on he solu ion among s akeholde s, i
is di icul o say when a p oblem is sol ed, and he e is no op ion o e e
he solu ions o he o me phase (e.g., Ri el & Webbe , 1973). Al hough
wicked p oblem is al eady an es ablished e m in design, in his esea ch,
I am gene ally alking abou complex se ices.
Design and heal hca e ha e had a long his o y oge he in heal hca e
imp o emen (Rowe, Knox, & Ha ey, 2020). The objec i e o heal hca e-
ela ed de elopmen can a y signi ican ly and may consis o he physical
a chi ec u e and in e io design o he holis ic se ice jou ney om he
pa ien ’s pe spec i e and he di e en ouchpoin s ela ed o he se ice.
I may also consis o all o he abo e elemen s oge he , whe e he se ice
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
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i sel is no con ined o he clinical encoun e s and physical bounda ies
o he building bu ex ends o a la ge numbe o di e en in e aces and
in e ac ions (Wols enholme, Cobb, Bowen, W igh , & Dea den, 2010).
This is a good illus a ion o how mul i-le eled and complex heal hca e
se ices a e. Public heal hca e has al eady applied pa ien in ol emen and
co-design app oaches (Nes a, 2013), bu hea y p essu e is pu on designe s
and hei success in “c ea ing some hing ha does no ye exis ” (Nelson
& S ol e man, 2012, p. 28). Al hough many s udies p esen e ol ing
bu ne e heless c i ical pe spec i es on he de elopmen o heal hca e
se ices, he e emains much wo k o be done o de e mine how se ice
design and co-design app oaches could suppo heal hca e- ela ed
de elopmen e en u he .
P e ious s udies ha e discussed whe e se ice design should ha e
i s place and impac in he de elopmen p ocess (e.g., Almq is , 2017,
2020; Cla wo hy, 2013; Raun, 2017 ; Yu & Sangio gi, 2014). In ac , some
o he ecen li e a u e has no ed ha he ea ly phase o he design p ocess,
he so-called uzzy on end, has al eady been in es iga ed and ecei ed
a lo o a en ion (Alam, 2006; Almq is , 2017, 2019; Cla wo hy, 2013;
Raun, 2017), and i is, he e o e, ime o ocus on he la e phases whe e
implemen a ion occu s, because design has no eached he desi ed capaci y
(Holmlid & Malmbe g, 2018; Malmbe g, 2017). Howe e , he on end is
he mos in o ma ion in ensi e. He e, di e en ypes o in o ma ion om
in e nal and ex e nal sou ces a e b ough in o he p ojec (Zahay, G i in,
& F ed icks, 2004), he majo decisions a e made (Cla wo hy, 2013), and,
o ins ance, eams and s akeholde s ge o know no only he gi en b ie
bu also each o he . I belie e ha he e a e oppo uni ies o de elopmen
in he ea ly phase o he design p ocess o engage s akeholde s and acili a e
hei pa icipa ion in se ice design and co-design and, hus, d i e change
in heal hca e o ganiza ions.
A change in heal hca e is uly needed (Ba e & Robe , 2007; F y,
2019; Jones, 2013) , bu he e is no s anda d o equal way o app oach hese
changes. As highligh ed in he li e a u e, change and ans o ma ion in
an o ganiza ion happen h ough lea ning (Kuu e, Mie inen, & Alhonsuo,
2014), and s a managemen is necessa y when changes mus be adop ed
and implemen ed in he heal hca e s a ’s wo k li e (e.g., Nilsen e al.,
2016; S ickdo n & Schneide , 2011), bu despi e his, he e is no one way
o app oach he changes. In design, he p ocesses canno be s anda dized
due o he e y di e en needs o de elopmen and mul i-laye ed and
siloed se ice s uc u es. Howe e , when aiming o change in complex
o ganiza ions, such as heal hca e o ganiza ions, we need o unde s and he

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
20 21
se ice ecosys em, which is impossible o design in i s en i e y including
con ex s and ac o s (Polaine, Lø lie, & Reason, 2013). By ou lining he
le els o di e en se ice ecosys ems, we can unde s and mo e p ecisely
he di e en laye s and he ela ionships be ween hem.
This esea ch has b oken down he ield o de elopmen in o h ee
di e en se ice ecosys em le els o suppo heal hca e- ela ed se ice
de elopmen . These se ice ecosys em le els a e, as Bei ão, Pa ício, and
Fisk (2017) has o mula ed, he mic o, meso, and mac o le els. He e, he
mic o le el ocuses on physicians and cus ome exchange se ices, se ice
ouchpoin s, and si ua ions wi hin a hospi al. The meso le el conside s
hospi al and o he heal hca e o ganiza ion in e ac ions, which can be a he
egional and local le els and in ol e public and p i a e sec o collabo a ion.
The mos challenging le el is he mac o le el, which inco po a es he
na ional le el wi h he go e nmen and Minis y o Heal h. The di ision
in o se ice ecosys em le els acili a es pe cei ing di e en and complex
heal hca e se ices, and consequen ly, he achie emen o objec i es is
mo e ealis ic. In any case, p ac ical app oaches a e needed o pe cei e
hese le els and o unde s and he alues o se ice design and co-design.
The e o e, his esea ch p oposes an al e na i e app oach.
This esea ch speci ically ocuses on and examines he ea ly phase
o heal hca e- ela ed se ice design o de e mine wha is needed be o e
s a ing an ac ual design p ocess o heal hca e se ice de elopmen in an
o ganiza ion and in eg a ing people om di e en backg ounds and wi h
di e en expe ise. I ocuses on he phase e en ea lie han he so-called
uzzy on end (e.g., Coope & Kleindschmid , 1986; Smi h & Reine sen,
1998). I am in e es ed in seeking ways o in e es hospi als in wha se ice
design and design ools can enable in heal hca e se ice de elopmen and,
h ough ha , b ing pa ien s, ela i es, and o he s in o co-design cycles and
de elop be e heal hca e expe iences o he u u e. I ha e ealized ha
some hing needs o be done be o e he ac ual heal hca e se ice design
p ocess can s a —a p ocess in which end use s (e.g., pa ien s o amily
membe s) and o he impo an s akeholde s a e mo e closely in ol ed
in he co-design. The e is a c ucial phase a he beginning o se ice
de elopmen ha should be dedica ed o people wo king in heal hca e
sec o , such as doc o s, nu ses, suppo s a , and managemen . The phase
ocused on unde s anding, e idence ga he ing, lea ning, and knowing
each o he is he phase ha I will discuss in mo e de ail in his disse a ion.
In e wined a ound his challenge a e ou academic a icles ha
oge he o m he p ac ical amewo k ha is he p inciple esul o his
esea ch. These academic a icles highligh h ee main heo ies: se ice
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
22
design, co-design, and heal hca e se ices. Se ice design has been a
na u al pa o my esea ch since he ea ly s ages o my ca ee , bu i also
p o ides a s ong heo e ical ield o se ice de elopmen , and hus, also
has s ong oo s in his esea ch. Co-design is widely used in he heal hca e
domain o unde s and he bigge pic u e o he ield (e.g., Pi inen, 2016;
T ischle , Die ich, & Rundle-Thiele, 2019; Vaajakallio, Lee, K onq is , &
Ma elmäki, 2013) and equi es c ea i e ini ia i e om he eams, which
include esea che s, designe s, and o he impo an s akeholde s, who a e
“expe s o hei expe iences” (Sleeswijk Visse , S appe s, Van de Lug ,
& Sande s, 2005, p. 127). Heal hca e se ices a e discussed h ough he
lenses o change and ans o ma ion, ex e nal and in e nal p essu e o
change, and exis ing app oaches o de eloping such se ices. This esea ch
does no ocus on he di e en heo ies o change and ans o ma ion bu ,
a he , sees hese as ields whe e se ice design is used and an a ea whe e
beha io is in luenced in one way o ano he .
The ou academic a icles a e he undamen al basis o my esea ch.
Nex , I will b ie ly in oduce hem. Sub-s udy I o his esea ch in es iga ed
he ole o se ice design ools and collabo a i e p ac ices in suppo ing and
de eloping se ice jou neys and he hospi al managemen p ac ice. The
a icle “Se ice Designing a New Hospi al o Lapland Hospi al Dis ic ”
(Mie inen & Alhonsuo, 2019) was published in he book Se ice Design
and Se ice Thinking in Heal hca e and Hospi al Managemen : Theo y,
Concep s, P ac ice, which a ge s hospi al manage s, p ocess manage s,
se ice designe s, o ganiza ional policymake s, leade s, and esea che s.
The chap e o his Sp inge book has a e y p ac ical slan . I in oduces
wo case s udies: (1) Benchma king heal hca e in Silicon Valley and (2)
Rehabili a ion p ocesses o child en li ing in Lapland. The case s udies
e eal wo signi ican a eas: benchma king and isual design me hods.
Benchma king is a as , cos -e ec i e app oach used o unde s and he
bes p ac ices and p esen s e idence o di e en managemen p ac ices
based on lean, agile, and human-cen e ed app oaches and he quali y,
e ec i eness, and imely a ailabili y o se ices. Visualized design me hods
and conc e iza ion ools suppo he communica ion and pe cep ion o a
mul i-laye ed, complex o ganiza ion. In addi ion, wo kshops whe e he
isualized da a a e ep esen ed and discussed a e a c ucial s a ing poin in
meso-le el de elopmen , whe e ac o s om public and p i a e hospi als,
pa ien s’ associa ions, o in o ma ion echnology (IT) endo s collabo a e
a he o ganiza ional, egional, and local le els (Bei ao e al., 2017).
The second a icle, “Designing New Hospi als – Who Ca es
abou he Pa ien s?” (Alhonsuo & Colley, 2019), is a sho pape ha was
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
22 23
p esen ed as a pos e . I desc ibes sub-s udy II o his esea ch, which
in es iga ed pa ien s’ expe iences in he p e-cons uc ion phase o new
hospi al and heal hca e se ice design. Al hough his esea ch did no
add ess he ole o pa ien s in he ea ly de elopmen , I became in e es ed in
new hospi al design and cons uc ion p ojec s, especially in how expe s in
his con ex unde s and, o example, he alues o co-design wi h pa ien s
and hei pa icipa ion in he cons uc ion p ojec s. E en hough p e ious
s udies s essed he po en ial bene i s o pa ien -cen e ed co-design (e.g.,
Done o e al., 2015), he esul s o case s udy 2 o his sub-s udy showed
he di e si y o opinions and challenges ega ding pa ien in ol emen in
hese kinds o hospi al cons uc ion p ojec s. The sub-s udy emphasized
ha challenges, such as limi ed imescales and esou ces, we e aced in he
use o co-designing and pa ien -cen e ed me hods. We ound ha a good
p ac ice o conc e izing heal hca e- ela ed se ices in he cons uc ion
phase, whe e many ideas a e s ill qui e abs ac , is i ual eali y (VR) and
physical eplicas o , o example, ea men ooms. This a icle c ea es an
unde s anding o how di e en ly design me hods a e u ilized in such a
massi e, complex, and expensi e de elopmen p ojec as he cons uc ion
o a new hospi al.
The hi d and ou h a icles ocus on heal hca e- ela ed design
sp in s. As men ioned p e iously, change and ans o ma ion a e opics
co e ed by his esea ch, and hus, design sp in s we e in es iga ed as
good oppo uni ies o ad ance cul u al shi s in o ganiza ions (Ku onen,
2017). I had an oppo uni y o in es iga e heal hca e- ela ed design
sp in s e en u he , which was ul ima ely a c ucial pa o he ou comes
o he esea ch. The hi d a icle (sub-s udy III), “Heal hca e Design
Sp in s: Wha Can Be Changed and Achie ed in Fi e Days?” (Alhonsuo,
Hookway, Sa an ou, Mie inen, & Mo us, 2020) p esen s an o e iew
o he s eng hs and weaknesses o heal hca e- ela ed design sp in s. I
discuss he challenges o change in design sp in s and how he syne gy
among pa icipan s was c ea ed h ough an agile way o doing. The inal
a icle (sub-s udy IV), “Pa icipa ion o Heal hca e Rep esen a i es in
Heal h- ela ed Design Sp in s” (Alhonsuo, Sa an ou, Hookway, Mie inen,
& Mo us, 2020) zooms in on a e y p ac ical le el o he design sp in s and
obse es he oles o heal hca e p o essionals om he iewpoin o how
hey can suppo design sp in s in he de elopmen o heal hca e- ela ed
se ices.
This academic esea ch is w i en wi h a e y p ac ical emphasis
and aims o each people wo king wi h design in he heal hca e ield, such
as heal hca e p ac i ione s, academics, and s uden s. I does no p o ide
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
24
eady-made answe s o u hs bu , a he , cons uc s my lea ning as an
inspi a ion o ackle he ea ly phase o he de elopmen p ocess. E en
hough he ocus is s ongly linked o heal hca e se ice design, he
ou comes can be scaled ac oss o he o ganiza ions. I hope you enjoy he
jou ney and whe e his esea ch will ake you.
1.2. My Resea ch Jou ney
Du ing my jou ney as a esea che , I ha e had oppo uni ies o wo k wi h
mul i-disciplina y eams and ge o know people wi h di e en esea ch
in e es s, backg ounds, and expe iences. I ha e hea d o and seen many
inspi ing academic jou neys. These s o ies ha e helped me ind my own
esea ch in e es and ha e opened doo s in he heal hca e ield—no only
in Finland bu also ab oad. In 2014, a e comple ing my heal h- ela ed
mas e ’s hesis in se ice design, I knew I wan ed o dig deepe in o he
heal hca e ield, no knowing how o e whelmed I would be by he numbe
o impo an and u gen challenges .
A ypical endency o se ice designe s is o obse e se ices a ound
you—especially he ones in which you a e e y in e es ed. This happens o
me, oo. I passiona ely obse e heal hca e se ices, wi h which I and people
close o me come in con ac . I conduc ed uno icial empi ical esea ch, o
example, in an eme gency polyclinic in Cape Town, Sou h A ica, a e I
had badly inju ed my hams ing; in a small clinic in Vancou e , Canada,
when I had high e e ; and also, in my home own o Ro aniemi when I
had e ible s omach pain. I obse ed he heal hca e my dea g and a he
ecei ed in his las yea s. Obse a ion has been su p isingly success ul, bu
i has included many sad s o ies om people a ound me. People ha e been
willing o sha e hei expe iences wi h me because o my esea ch in e es ,
knowing ha due o e hical conside a ions, I mus keep hei s o ies inside
me and no make hem pa o my esea ch. Those s o ies ha e pushed
me o con inue my esea ch and ha e eminded me many imes why I am
doing his. They ha e gi en me mo i a ion o con inue e en hough he
oad has been ocky. He e, I would like o exp ess my hea el g a i ude o
hose anonymous people.
The complex heal hca e PhD jou ney was no s aigh o wa d. I was
o e whelmed wi h he nume ous in e es ing a eas and ca ing p ocesses o
conside . I wan ed o s a wi h pallia i e ca e and end-o -li e expe iences,
bu I ealized qui e soon ha I was no eady o jump in o ha da k wa e . I
eplanned my esea ch and decided o s udy hospi al cons uc ion p ojec s
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
30 31
p esen s he main indings and ou comes om he ou sub-s udies, which
a e con ained in hei own espec i e subsec ions. A he end o Sec ion 4,
I summa ize he key indings using ables. Sec ion 5. Discussion p esen s
he main empi ical indings and desc ibes hem in e ms o he heo e ical
amewo k. He e, he p ac ical amewo k is p esen ed. Finally, Sec ion 6.
Conclusion w aps up he disse a ion by discussing i s impac and o e s
sugges ions o u u e esea ch.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Pic u e: Maileena Tuokko
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
33
The ollowing subsec ions de ine he heo e ical backg ound o he esea ch,
which comp ises se ice design, co-design, and heal hca e se ices. Fi s ,
he se ice design subsec ion in oduces a b ie his o y o he se ice design
app oach, i s di e en p ocesses in design and de elopmen , and he mos
commonly used design me hods when in e playing be ween di e en
se ice le els. Second, he co-design ield is discussed conce ning i s
connec ion o se ice design and heal hca e. Thi d, heal hca e se ices a e
examined om he pe spec i es o o ganiza ional change and heal hca e
de elopmen .
2.1. Se ice Design
The di e ence be ween p oduc s and se ices is mo e han seman ic.
P oduc s a e angible objec s ha exis in bo h ime and space;
se ices consis solely o ac s o p ocess(es), and exis in ime only.
The basic dis inc ion be ween “ hings” and “p ocesses” is he s a ing
poin o a ocused in es iga ion o se ices. Se ices a e ende ed;
p oduc s a e possessed. Se ices canno be possessed; hey can only
be expe ienced, c ea ed o pa icipa ed in.
(Shos ack, 1982, p. 49)
These wo ds opened Shos ack’s (1982) a icle “How o Design a Se ice.”
Se ice design as a design discipline has aken a huge s ep o e he las
wo decades, since academia and he public and p i a e sec o s a ound he
wo ld ealized ha se ices domina e economic g ow h (Bi ne , Os om,
2. Theo e ical Backg ound
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
34
& Mo gan, 2008). Besides se ice design, he disciplines o ma ke ing,
managemen , and enginee ing ha e had g ea inpu in o he g owing
se ice sec o (Me oni & Sangio gi, 2011). Acco ding o Ed a dsson,
Gus a sson, and Roos (2005) and Mage (2004), he ole o se ice design
should be seen mo e as a complemen a y ield in se ice de elopmen ,
managemen , and ma ke ing. Se ice design aims o sys ema ically apply
design me hods and p inciples o he design o se ices, and i “in eg a es
he possibili ies and means o pe o m a se ice wi h he desi ed quali ies,
wi hin he economic and s a egic in en o an o ganiza ion” (Holmlid &
E enson, 2008, p. 341). Se ice design is a human-cen e ed, collabo a i e,
and c ea i e app oach (Blomk is , Holmlid, & Segels öm, 2010; Me oni
& Sangio gi, 2011) and is also conside ed a way o hinking as a pa o
p ac ices o se ice inno a ions (S ickdo n & Schneide , 2011). Recen ly,
se ice design has been p oposed as a mul idisciplina y p ac ice in se ice
inno a ion (Os om e al., 2015; We e -Edman e al., 2014), which uses
“‘designe ly’ ways o changing and inno a ing” (Sangio gi & Junginge ,
2015, p. 166).
The de ini ion o se ice design has no always been
s aigh o wa d. O e he yea s, he e ha e been discussions, o ins ance,
on di e en ways o app oaching se ice design and he ole o se ice
om a ious disciplina y pe spec i es (e.g., Bi ne , Booms, & Te eaul ,
1990; Cla wo hy, 2010; Mage , 2008; Mo elli, Gö zen, & Simeone, 2021),
and how he wo k o se ice design is unde s ood (Kimbell, 2011a). As an
example, Kimbell (2011a) di ided se ice design in o wo main ensions,
whe e he i s ension ocuses on “unde s anding design ei he as p oblem-
sol ing ha aims o ealize wha has al eady been concei ed o , o as an
explo a o y enqui y in ol ing cons uc ing unde s anding abou wha
is being designed, in ol ing end use s and o he s in c ea ing meaning,”
and he second conside s “a ension be ween he iew ha he dis inc ion
be ween goods and se ices ma e s signi ican ly, o ha se ice is be e
unde s ood as a undamen al ac i i y wi h mul iple ac o s wi hin a alue
cons ella ion” (p. 45).
Ano he widely e e ed o pe spec i e comes om Va go and
Lusch (2004, 2008), who a gued ha he e a e wo di e en dominan
logics: a goods-dominan logic (G-D logic) and a se ice-dominan
logic (S-D logic). B ie ly, G-D logic can be seen “as a ca ego y o ma ke
o e ings” (Ed a dsson e al., 2005, p. 118); in o he wo ds, i is a iew o
p oduc s. He e, he pu pose o economic ac i i ies is o dis ibu e goods
ha can be sold and whe e use s a e passi e in he p ocess. In S-D logic,
in con as , se ices a e he p ima y uni o exchange whe e use s and
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
34 35
cus ome s a e ac i ely pa o he se ices (Mo elli e al., 2021; Va go &
Lusch, 2004), and hus, “ alue c ea ion is bes unde s ood om he lens o
he cus ome based on alue in use” (Ed a dsson e al., 2005, p. 107). Thus,
se ices can be unde s ood as a dynamic p ocess whe e alue is co-c ea ed
(Va go & Lusch, 2004). S-D logic was i s in oduced by Va go and Lusch
(2004, 2008) in he ea ly 2000s, when he oles o se ices and goods we e
analyzed and iden i ied.
S-D logic iden i ies se ice ecosys ems as he “uni ” o analysis
o alue co-c ea ion (Va go & Lusch, 2017). The concep o a se ice
ecosys em o e s a amewo k o esea ch ocused on, o example, esou ce
in eg a ion as an impo an means o connec ing people and echnology
wi hin and among se ice sys ems (Va go & Akaka, 2012), o as Va go
and Lusch (2014) desc ibed i , he se ice ecosys em is a “ ela i ely sel -
con ained, sel -adjus ing sys em o esou ce-in eg a ing ac o s connec ed
by sha ed ins i u ional a angemen s and mu ual alue c ea ion h ough
se ice exchange” (p. 24). The ecosys em amewo k can p o ide c ucial
insigh s when inno a ing se ices sys ema ically and desc ibing heal hca e
en i onmen s mo e accu a ely (Mie inen & Alhonsuo, 2019). He e, we
mus unde s and ha heal hca e is no only a mul i-laye ed p ocess in a
hospi al con ex bu also pa o a bigge pic u e as a componen o he
social wel a e and public se ice s uc u e.
A complex ecosys em in i s en i e y including con ex s and ac o s
is impossible o design (Polaine, Lø lie, & Reason, 2013), and he e m
ecosys em needs o be iewed c i ically, as i may be misleading. Me can
and Gök as (2011) c i icized he popula ized e m “ecosys em,” whose
o igin is in biology and e e s o a holis ic na u al and sus ainable sys em,
which is wha heal hca e may be s i ing owa d. My esea ch ollows
Bei ao e al.’s (2017) h ee le els o he se ice ecosys em: he mic o, meso,
and mac o le els. In his disse a ion, I will u ilize and desc ibe hese le els
and mi o hem in he heal hca e con ex o be e unde s and he scales o
de elopmen . He e, he mic o le el includes pa ien –doc o in e ac ions o
si ua ions wi hin he hospi al whe e ouchpoin s ha e an impo an ole in
he in e nal p ocesses. Touchpoin s a e angible o in angible in e ac ions
o con ac poin s be ween he end use and he se ice p o ide (S ickdo n
& Schneide , 2011). As a le el, i is usually he simples o design and wo k
wi h because he impo an s akeholde s a e easily eachable.
The meso le el ocuses on hospi al and o he heal hca e o ganiza ion
in e ac ions and, hus, eaches he egional and local le els. This can be
collabo a ions be ween public and p i a e hospi als, pa ien associa ions,
and IT endo s. This le el al eady equi es mo e p epa a ion compa ed o
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Mac o le el
inco po a es he na ional le el
wi h ac o s such as go e nmen
and Minis y o Heal h
Mic o le el
si ua ions wi hin he hospi al
e.g. pa ien -doc o in e ac ion, also ouchpoin s
??
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
Meso le el
an o ganiza ional, egional, and local le el,
whe e ac o s om e.g. public and p i a e hospi als,
pa ien s associa ions, o IT endo s a e collabo a ing
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
In oIn oIn oIn oIn oIn o
36
he mic o le el ha akes in o accoun he possibili ies and needs o o he
and di e en hospi als o bo h smoo h collabo a ion and a commi men
o de eloping hei ope a ions. The highes and mos complex le el is he
mac o le el ha conside s go e nmen and o he o ganiza ions’ ac ions
and, hus, also desc ibes well he de ini ion o wicked p oblems, as i
in ol es poli ical decision-making.
This h ee-le el model has simila i ies wi h he se ice de ini ions
o Mo elli, Gö zen, and Simeone (2021) iden i ying se ices as (1)
in e ac ions be ween unbalanced oles (e.g., pa ien and doc o ); (2) an
in as uc u e ha suppo s he in e ac ions o o he se ice ac i i ies; and
(3) a sys emic ins i u ion ha o ganizes he se ice ac i i ies and p ocesses
(pp. 11–12). These h ee a eas a e ex emely impo an in se ice design,
and hey all aim o c ea e alue h ough he di e en le els. The le els de ine
di e en possible con ex s o design and can be seen as an ecosys em ha
is ela ed o he p oduc ion o alue. Figu e 2 isualizes he h ee le els o
a se ice ecosys em in he heal hca e ield, which is also conside ed la e
in his disse a ion.
Figu e 2. An o e iew o he mic o, meso, and mac o le els in heal hca e. (Au ho ’s
illus a ion)
Value is co-c ea ed a hese le els; howe e , om my expe ience, hey
equi e a sligh ly di e en app oach and unde s anding om he o he

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
36 37
2.1.1. Role o he Se ice Designe
The se ice designe ’s ole is no longe one o an expe who designs and
deli e s solu ions bu o a acili a o who guides s akeholde s h ough he
co-design p ocess (Yu & Sangio gi, 2017). Se ice designe s “collec , lis en
o, and syn hesize di e en pe spec i es o suppo he non-designe s’
c ea i e e o s and guide he di e en inpu s owa d a aluable solu ion”
(Malmbe g e al., 2019, p. 9). They gi e people a space whe e hey ha e
pe mission and he powe o in luence a design p ocess, and h ough
cyclic co-design wo k, di e en design me hods can be de eloped u he
o allow pa icipa ion, engagemen , and c ea i i y (Mie inen, 2013).
Design hinking is an in eg al pa o se ice design as well as he
se ice designe ’s mindse . Acco ding o Mie inen, Ron i, Kuu e, and
Linds öm (2012), he common cha ac e is ics o good design hinke s
a e empa hy, in eg a i e hinking, op imism, expe imen alism, and
collabo a ion. Design hinking should no be seen only as a mindse o
se ice designe s. The se ice designe s mus seek o ans e his mindse
o o he s akeholde s and pa icipan s as well, because “Holis ic se ice
design is based on an in e ela ed and sys ema ic app oach s a ing wi h
design hinking ha ing use -d i en design in i s ack” (P anns iel &
Rasche, 2019, p. i). Design hinking leads s akeholde s in design eams
h ough a sys ema ic app oach owa d se ice inno a ion (Ve e li &
Sche e , 2019), and in he bigge pic u e, o ganiza ions mus unde s and
(se ice) design hinking o be able o edesign se ices in inno a i e ways
(Clack & Ellison, 2019). Hence, se ice designe s should conside he
impo ance o design hinking a a e y ea ly s age in he design p ocess.
The ields whe e se ice designe s ac a e wide. Fo ins ance,
hey can wo k as in-house designe s o consul an s in p i a e small
and medium-sized en e p ises (SMEs), la ge public o ganiza ions and
indus ies, o associa ions o socie ies (clubs). The heal hca e ield, on
which his esea ch ocuses, can also be e e ed o as ha ing wicked
p oblems (see, e.g., Buchanan, 1992; Ri el & Webbe , 1973; Suoheimo,
2020), which means ha hese p oblems a e highly “complex, in e wined
pa ies in ol ed in he de elopmen p ocess. F om his poin o iew, i
is impo an o cla i y one’s own unde s anding o wha can be designed,
how, and wi h whom. I is especially impo an in ields whe e se ice
design is no well known. This issue also o e laps wi h o he a eas o my
esea ch and will be add essed in he discussion.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
38
wi h many o he p oblems, and p obably no ‘sol able’ in he way we a e
used o hinking abou sol ing p oblems” (Polaine e al., 2013, p. 186). In
hese complex con ex s, se ice designe s a e engaged in si ua ions whe e
special skills a e equi ed, o ins ance, iden i ying he emo ional skills o
pa icipan s in wo kshops and co-c ea i e p ac ices (So o, 2021). Syne gy
is also needed among pa icipan s and o he in ol ed s akeholde s, and
i can be c ea ed h ough design me hods and design hinking. He e, as
was de e mined in a icle 4 (sub-s udy IV) by Alhonsuo, Hookway, e al.
(2020), he se ice designe ’s ole is o boos he syne gy wi hin a eam.
A ypical way o a se ice designe o wo k is as an ex e nal
consul an (Almq is , 2019). Thus, se ice designe s a e o en in ol ed
in he ea ly phase o he de elopmen p ocess; howe e , his has been
c i icized in many ecen s udies. The c i icism highligh s, o example,
ha he designe ’s job is o ocus on iden i ying use insigh s and idea
gene a ion and hen lea e he de elopmen p ojec s wi h use insigh
knowledge in hei hands (Almq is , 2017, 2020). This is called “use
insigh d i ” (Almq is , 2017, p. S2524), when he use ’s needs and
se ice expe iences a e no longe linked and, hus, canno ha e an impac
on he inal se ice solu ion and i s implemen a ion. The designe he e is
an impo an link be ween bo h he end use s and he o ganiza ion, o
example. I does no ma e i he designe is a consul an o a pe manen
playe in he o ganiza ion, bu he deep and de ailed in o ma ion ga he ed
by he se ice designe should no , in my opinion, be los . I is impo an
o emphasize he ole o se ice designe h oughou he de elopmen
p ocess and make his clea igh a he beginning o he p ocess.
Se ice designe s can ha e an impac on pee - o-pee lea ning
h ough collabo a i e wo k (Kuu e & Mie inen, 2013) and he lea ning
p ocess o pa icipan s, which can suppo , o example, changes in co-
design p ocesses and se ices (Kuu e e al., 2014). Acco ding o Sangio gi
(2011), he e ol ing ield o se ice design is mo ing owa d a o m o
design o ans o ma ion, whe e he se ice design is no only changing
he se ice i sel bu also changing he capaci y inside he o ganiza ions
and communi ies o s ee changes hemsel es. Se ice design is explo ed
as a ca alys o o ganiza ional change and ans o ma ion (Junginge ,
2015; Yu & Sangio gi, 2018), bu i equi es s akeholde s’ pa icipa ion in
he se ice design p ocess o impac and change beha io (We e -Edman,
Vink, & Blomk is , 2018). F om his pe spec i e, se ice designe s a e
becoming inc easingly needed in a ious a eas o ou social and economic
sys ems, and hus, hei capabili ies should be explained in de ail (Mo elli
e al., 2021).
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
38 39
In he li e a u e aiming o change in heal hca e o ganiza ions, we
o en encoun e e ms and heo ies ela ed o, o ins ance, ans o ma i e
change and ans o ma ional change (e.g., Sangio gi, 2011), change
managemen (e.g., Lin, Hughes, Ka ica, Dining-Zube , & Plsek, 2011),
o ganiza ional change (Julie , 2006), and ins i u ional change (Sco , Rue ,
Mendel, & Ca onna, 2000). In his disse a ion, I mainly e e o change and
ans o ma ion as men ioned in he con ex and li e a u e. Medina (2018)
dis inguished be ween he wo e ms as ollows: change is, o example,
Mo ing people om one depa men o ano he , adding o emo ing
a laye in he hie a chy, assigning new manage s, c ea ing o
enaming oles, ec ui ing some new people, o slimming down he
o ganiza ion, is abou change. The essence is s ill he same, no hing
new has been c ea ed om he o iginal componen s. (pa a. 9)
T ans o ma ion in an o ganiza ion is “changing he essence, abou c ea ing
some hing new based on he old pa s; i is abou u ilizing he po en ial
and capabili ies in a di e en way” (pa a. 10). Rela ed o ans o ma ion,
he li e a u e has in oduced ans o ma i e change and ans o ma ional
change. As I also use hese e ms se e al imes in his disse a ion, I eel i
impo an o cla i y hei meanings. T ans o ma i e change is a p ac ical
and s a egic p ocess ha igge s ans o ma ion and e ec s change
wi hin an o ganiza ion and, hus, can be seen as a b oad-based change.
T ans o ma ional change “al e [s] wha we do, no jus how we do wha we
do” (Moss, 2017, pa a. 6). I leads o ans o ma ion and eshapes p ocesses
and s a egies and, hus, can shi he cul u e in an o ganiza ion. Wi h he
la e e m, he ocus is mo e on he p esen and wha is happening a he
momen .
This esea ch does no ocus on he di e en heo ies o change
and ans o ma ion bu , a he , sees hese app oaches as an impo an
pa o se ice de elopmen and di e en le els o se ice ecosys ems.
Fu he mo e, when a se ice design consul an en e s in o a de elopmen
p ojec , hey migh no ye ha e any idea abou wha le el o change o
ans o ma ion ela es o he de elopmen . This knowledge is impo an
o unde s and and discuss a he ea ly s age o he de elopmen p ocess
o ensu e ha he desi ed ou comes o he p ojec can be achie ed. In
addi ion, I see i as impo an o examine change and/o ans o ma ion
a he mic o, meso, and mac o le els, whe e o ganiza ional s uc u es can
be be e pe cei ed. In his esea ch, I conside he mac o le el in e ms
o he ans o ma i e change, he meso le el in be ween ans o ma i e
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
40
and ans o ma ional change, and he mic o le el as zooming in on he
ans o ma ional change.
2.1.2. Di e en P ocesses in Design and De elopmen
The design landscape oday is cha ac e ized by con lic and con usion,
e iden in a g owing ealiza ion ha an icipa ion o he needs and
d eams o people is necessa y bu a he same ime e y di icul o do.
We see u ba les be ween designe s and esea che s as designe s
y o conduc hei own esea ch and esea che s s uggle o do
wo k ele an o design. Wi h mo e and mo e disciplines becoming
in ol ed in he on end o he p ocess, he e is discon en be ween
disciplines a mul iple bo de s.
(Sande s, 2010, pp. 117–118)
He e, mo e han 10 yea s ago, Sande s desc ibed he design landscape
and he ole o designe s and esea che s in he ea ly phase o he design
p ocess, whe e people om di e en disciplines exp ess hei own will.
The wo ld has no changed much, and hese s uggles and con lic s s ill
exis . In his subsec ion, I will discuss his opic u he om he design
p ocess pe spec i e.
The design ield is ull o di e en modi ica ions o de elopmen
p ocesses. This is because, o e he yea s, design esea ch has emphasized
he p ocess o design, which has p o en o be a powe ul ool when
de eloping design educa ion and p ac ice (Do s , 2008). Cu en ly,
he design discipline is seen as a way o designe s o c ea e inno a i e
solu ions o complex p oblems by hinking and s uc u ing he design
p ocess (Mie inen & Sa an ou, 2019). The design p ocess can be desc ibed
as “ he speci ic se ies o e en s, ac ions o me hods by which a p ocedu e
o se o p ocedu es a e ollowed, in o de o achie e an in ended pu pose,
goal o ou come” (Bes , 2015, p. 208). Al hough design p ocesses a e o en
isualized as a linea s uc u e wi h clea phases, in he eal wo ld, hey
a e mo e non-linea and i e a i e, including he many di e en needs o
end use s and cus ome s. Fo his eason, design p ocesses a e di icul o
s anda dize (Bes , 2015).
We can see he oo s o he se ice design p ocess in he new
p oduc de elopmen (NPD) p ocess o he 1980s, when he need o a
mo e sys ema ic and linea p oduc - ela ed de elopmen p ocess was
ecognized (Booz, Allen & Hamil on, 1982; Coope & Kleindschmid ,
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
46 47
ac i i ies i sel , which is emphasized as a e y impo an inding in sub-
s udies III (Alhonsuo, Hookway, e al., 2020) and IV (Alhonsuo, Sa an ou,
e al., 2020) o his esea ch.
Design sp in s
The design sp in app oach is an in ensi e, ypically i e-day-long design
p ocess including he elemen s o agile, design hinking, and lean s a -up
(Knapp, Ze a sky, & Kowi z, 2016). The idea o he design sp in app oach
eme ged in 2009 when Jake Knapp (2016) was wo king a Google and
wan ed o imp o e eam p ocesses. This app oach is usually applied by
a small eam and “se es o maximize he chances o making some hing
people wan ” (Ban ield, Lomba do, & Wax, 2016, p. 5). I is p ima ily used
in s a -up en i onmen s whe e digi al, so wa e, and p oduc inno a ion
a e unde de elopmen . The design sp in amewo k helps sp in eams
answe c i ical business ques ions h ough apid p o o yping and use
es ing. Th ough a igid and acili a ed p ocess and elemen s o agile, lean,
and design hinking, eams p oduce a minimum iable p oduc (MVP)
o se ice (MVS) as an ou come o he sp in (Magis e i, T abucchi,
Dell’E a, & Buganza, 2019). The design sp in p ocess by Knapp e al.
(2016) is isualized in Figu e 6.
Figu e 6. The design sp in p ocess. (Adap ed om Knapp, Ze a sky, and Kowi z, 2016;
Au ho ’s illus a ion)
A design sp in is an in ensi e way o wo king, and i has simila i ies wi h
hacka hons, whe e eam membe s collabo a e in ensi ely and wo k ad hoc

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
48
on a design p ojec (Madson, 2021). Sp in s a e good oppo uni ies o lea n
new cus ome -cen e ed ways o wo king and, hus, ad ance cul u al shi s
in o ganiza ions (Ku onen, 2017). The design sp in b ings s akeholde s
oge he , bu as Knapp e al. (2016) cla i ied, indi iduals who wo k alone
gene a e be e ideas han when b ains o ming ou loud in g oups. Knapp
e al. no ed ha “wo king alone o e s ime o do esea ch, ind inspi a ion,
and hink abou he p oblem. And he p essu e o esponsibili y ha comes
om wo king alone o en spu s us o ou bes wo k” (p. 107). Howe e ,
each o us may ecognize a si ua ion whe e in ense wo k cons an ly
e ol es in he mind and ideas a e p ocessed when he wo kday is o e .
Fo his eason, i is impo an o o e ools o pa icipan s o help hem
ake ad an age o hei hough s. Howe e , he ole o he design sp in
acili a o is o guide and manage om a me hodological pe spec i e and
no in luence he decision-making p ocess (Knapp e al., 2016).
A small amoun o esea ch has been conduc ed on design
sp in s in he social and heal hca e ield (Valen ine, K oll, B uce, Lim, &
Moun ain, 2017; Vechakul, Sh imali, & Sandhu, 2015), al hough design
sp in s can be seen as a g ea way o in ol e and engage a busy heal hca e
s a on a igh schedule. As highligh ed in a icle 3 in his esea ch by
Alhonsuo, Hookway, e al. (2020), a design sp in p ocess does no aim o
ei he polished o inished ou comes o se ice concep s ha a e eady o
implemen . The ideas a e ela i ely weak and no s uc u ed o pe ec ly
i in complex heal hca e ecosys ems. One challenge in implemen ing
se ice concep s in he heal hca e ield is ha he se ice solu ions ail
because hei implemen a ion is pe cei ed as uns able o un ocused (F y,
2019; Nilsen e al., 2016). In addi ion, s a managemen is needed when
new se ice changes mus be adop ed in he wo k ou ines in a hospi al
(e.g., Nilsen e al., 2016; S ickdo n & Schneide , 2011). F om his poin
o iew, he e is no enough ime du ing he design sp in o ackle he
abo emen ioned challenges, bu he p oduced ideas and he design sp in
p ocess wi h i s c ea i e me hods can be a s a ing poin o a ec ing
change in o ganiza ions.
In addi ion, I canno help bu hink o he ole o design sp in
om he pe spec i e o agile de elopmen , apid p o o yping, and quick
use es s, which enable ailing as and o en. This was also emphasized
in a s udy by Valen ine e al. (2017) and can de ini ely be seen as a alue
in heal h- ela ed se ice design app oaches, which o e di e en ools
and me hods o apid conc e iza ion. Howe e , a his poin , I wan o
highligh he alue o lea ning h ough design sp in s, which is seen as a
key inding o he a icles o his esea ch by Alhonsuo, Hookway, e al.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
48 49
(2020) and Alhonsuo, Sa an ou, e al. (2020). Lea ning is conside ed he
lea ning o design hinking and design me hods in hese a icles.
2.1.3. In e play be ween Di e en Se ice Le els
In his subsec ion, I will in oduce di e en design me hods ha ha e
played a signi ican ole in his esea ch. I will keep he main ocus on
isualiza ion and conc e iza ion me hods, as hey had a majo impac on
he esea ch o e all. I will also discuss he alues o design me hods in
pe cei ing di e en se ice le els and he in e play be ween hem. Fi s , I
will p o ide a li le backg ound o design me hods.
Di e en design me hods ha e had a signi ican ole in he design
ield since he la e 1950s (Bayazi , 2004), and he in e es in hem has
sp ead beyond he design ield as he a en ion o design hinking has
inc eased (Kimbell, 2011b). The gene al me hod ha se ice design uses
is e hnog aphic esea ch (e.g., Segels öm & Holmlid, 2015), which aims
o ga he a holis ic pic u e o he esea ched opic, engage he ele an
s akeholde s, and unde s and hei expe iences by in e iewing and
obse ing hem (C eswell, 2014).
Se ice design uses a ious isualiza ion and conc e iza ion ools
and me hods (Koh, Slingsby, Dykes, & Kam, 2011; Shneide man, Plaisan ,
& Hesse, 2013), which aim, o ins ance, o isualize and unde s and use
expe iences (P endi ille, Gwil , & Mi chell, 2017; Segels öm, 2013) o
s ep in o ano he pe son’s shoes h ough p o o yping (Blomk is , 2016)
and ole-playing (Kaa io, Vaajakallio, Leh inen, Kan ola, & Kuikkaniemi,
2009). In se ice design, isualiza ion is used h oughou he design
p ocess. In he disco e y phase, o ins ance, ques ionnai es, in e iews,
esea ch dia ies, and design p obes can be isualized o make he ma e ials
mo e use iendly and c ea i e o s akeholde s o ill ou . In he de ine
phase, he da a om he ield a e analyzed in a mo e unde s andable way
and, he e, he isualiza ion usually plays an impo an ole. This phase
u ilizes, o ins ance, di e en pe sonas and mapping ools, aiming o
make sense o he da a and de ine he insigh s and eal challenges. The
mappings and modellings a e e y common design me hods o se ice
designe s (Pa ício, Fisk, Falcão e Cunha, & Cons an ine, 2011), such
as use jou ney mappings, s akeholde mappings, s uc u ed se ice
bluep in s (Bi ne e al., 2008; Pa ício, Fisk, & Falcão e Cunha, 2008), and
se ice walk h oughs (Blomk is & Bode, 2012). Figu e 7 p esen s a ew
examples o isualiza ion me hods.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
50
Figu e 7. Di e en isualiza ion me hods in p ac ice. Top le : s o yboa d (Pic u e:
Maileena Tuokko); op igh : pa ien se ice jou ney (Pic u e: Mi a Alhonsuo); bo om
le : de ined use insigh s on a pos e (Pic u e: Maileena Tuokko); bo om igh : desk op
walk h ough (Pic u e: Maileena Tuokko)
In he de elopmen phase o he design p ocess, which is a phase o
de eloping po en ial solu ions (Design Council, 2015), he mo e conc e e
design me hods a e in oduced, such as p o o yping me hods. Se ice
p o o yping is a “goal-o ien ed bu play ul way” (Schulz, Gei hne , Woel el,
& K zywinski, 2015, p. 323) o build and es di e en se ice ideas.
Tangible and conc e e communica ion ools e ec i ely suppo co-design
p ocesses in communica ion opics, which migh be di icul o a icula e
o he wise (Rygh & Cla wo hy, 2019). P o o yping also has alue because
i bene i s he design p ocess by sa ing esou ces, such as ime and money
(Blomk is , 2014), and hus, i is a aluable me hod o implemen , o
ins ance, in new hospi al cons uc ion p ojec s, whe e he ime p essu e
is igh , especially a he beginning, as s essed in sub-s udy II o his
esea ch by Alhonsuo and Colley (2019). P o o yping has simila i ies
wi h simula ion, which is no a new me hod in heal hca e (Poikela,
2017). Thus, p o o yping can p o ide new ea u es o suppo simula ion.
Fu he , se ice p o o yping is a ool o lea ning abou and implemen ing
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
50 51
ans o ma i e changes (Kuu e, Mie inen, & Alhonsuo, 2014), and hus,
i s impac on he de elopmen o heal hca e se ices can be signi ican . In
his s udy, se ice p o o yping was ca ied ou in case s udy 2 o sub-s udy
I and in he design sp in s o ganized in sub-s udies III and IV. I was only
u ilized in e y apid use es ing, bu was ne e heless seen as impo an ,
o example, as pa o he benchma king p ocess. Figu e 8 below shows
some p o o yping pic u es om he design sp in s. The inal phase is
usually o deli e ing he se ices ha wo k (Design Council, 2015) and
implemen ing hem in he mo e s a egic phase, whe e he isualiza ions
a e inalized o explain and in e p e a se ice concep in mo e de ail.
Figu e 8. Se ice p o o yping and ole-playing. On he le : ole-play ac ion – me as a
nu se. On he igh : design sp in eams p epa ing a use es o hei se ice concep .
(Pic u es: Maileena Tuokko)
Acco ding o Hakio and Ma elmäki (2011) explo a o y, pa icipa o y,
and isual design me hods i well o enhance he c oss- unc ional
collabo a ion in public o ganiza ions, whe e public heal hca e belongs.
The alue o isualiza ion me hods is ha hey cla i y he complex se ices
and di e en se ice le els. S epping in o he shoes o ano he allows o a
mo e de ailed look a he se ice. The e a e hund eds o design me hods o
scaling se ices, and especially in mul i-laye se ices, such as heal hca e
se ices, we need o zoom in and zoom ou o ob ain an o e all pic u e
o he di e en de ails, momen s, and p ocesses in a imeline. As Polaine
(2013) desc ibed, he p ac ice o se ice design is a con inual p ocess whe e
we zoom in and ou o see he de ails o achie e an o e iew. In se ice
design e minology, we use he e ms use jou ney, se ice momen , and
ouchpoin s. These h ee a eas help us o scale h ough he mul i-laye ed
se ices.
The se ice jou ney (also known as use jou ney, cus ome jou ney,
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
52
and pa ien ’s jou ney) isualizes he p ocess o se ice in a imeline. The
se ice jou ney is di ided in o se ice momen s, which help o speci y
di e en needs and challenges in each phase. These momen s consis o
mul iple ouchpoin s, which a e c ucial elemen s equi ed o p o ide
success ul se ice. The se ice jou ney can be seen as a na a i e, which
ells a s o y o one’s expe iences, and ouchpoin s a e angible o in angible
in e ac ion o con ac poin s be ween he end use and he se ice p o ide
(S ickdo n & Schneide , 2011). Th ough ouchpoin s, we can in es iga e,
o example, how a e e al is guiding a pa ien h ough he p epa a ion o
hei ca e plan, how clea he in o ma ion sign is a he en ance, o how
music a ec s hei eelings while wai ing o hei doc o ’s appoin men in
a hallway. The ouchpoin can be a lye a ca egi e hands ou o a pa ien
abou hei illness o a no i ica ion message eminding hem abou an
upcoming appoin men . These di e en ouchpoin s a e a c ucial pa o
he holis ic p ocess.
In e play be ween di e en se ice le els is impo an o se e al
easons. Fi s , isualized se ice jou ney mapping helps o pe cei e a
holis ic pic u e o a speci ic heal hca e- ela ed se ice. Jou ney maps “can
show many o he o e a ching alues and he one o oice o a se ice
using a pa ial iew” (S ickdo n e al. 2018, p. 51). In heal hca e- ela ed
se ice de elopmen , his is impo an when he scale o a pa ien ’s jou ney
can ange om a quick (a ew minu es) labo a o y isi o yea s o s uggle
wi h cance o a li elong disease, such as diabe es. The se ice jou ney is an
eye-opening me hod o see di e en nuances and insigh s in a se ice, and
i is a good ool o s a he discussion. F om ano he poin o iew, se ice
jou ney mapping can o e he i s iew o he heal hca e ecosys em and
insigh s no only om he pa ien s’ poin o iew bu also om ha o
heal hca e p o essionals.
As an example, h ough he se ice jou ney, we migh see ha
pa ien s do no ind he way o he igh wa d a he hospi al, and hus, i
akes hem ex a ime o na iga e and ask s a o help. A e his inding,
we can jump in o he second s ep, zooming in o he se ice momen s,
and obse e why his na iga ion is di icul and whe e he misguidance
happens. We migh see ha in o ma ion is lacking in some o he se ice
momen s. We can hen idea e and es di e en se ice solu ions in hese
momen s and see how hey wo k in eal li e. The las impo an iewpoin ,
which conce ns why scaling heal hca e is impo an in his esea ch, is o
see how ouchpoin s can suppo holis ic se ice. He e, o ins ance, he
pa ien has ecei ed a pape wi h a de ailed desc ip ion o whe e o go nex
o an applica ion na iga es hem inside he hospi al.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
52 53
The abo emen ioned elemen s build he puzzles oge he , o ming
he pic u e o in e nal and ex e nal ecosys ems. Se ice jou ney mapping
can be one way o unde s and pa ien jou ney app oaches, which
Simonse, Albay ak, and S a e (2019) no ed is lacking documen a ion in
he li e a u e. Thus, my esea ch ocuses on he e y ea ly phase o he
de elopmen p ocess and discusses, o ins ance, wi h whom and how he
e y ea ly phase o se ice design p ac ices should be done so ha e ec i e
collabo a ion and unde s anding among di e en s akeholde s can be
sough , and hus, a design-d i en p ocess wi h i s unc ions can be lea ned,
emb aced, and accep ed in heal hca e- ela ed se ice de elopmen .
2.2. Co-design
In my esea ch, I ollowed he co-design app oach, which sha es simila
undamen als wi h co-c ea ion, and hus, hey a e o en conside ed o
be he same. Sande and S appe s (2008) e e ed o co-c ea ion as “any
ac o collec i e c ea i i y, i.e. c ea i i y ha is sha ed by wo o mo e
people” and co-design as a “collec i e c ea i i y as i is applied ac oss he
whole span o a design p ocess” and “ o he c ea i i y o designe s and
people no ained in design wo king oge he in he design de elopmen
p ocess” (p. 6). Co-design gi es a oice o people who ha e no been pa
o collabo a i e wo k be o e in he belie ha e e ybody is c ea i e in
he igh en i onmen . I equi es c ea i e ini ia i e om eams, which
include esea che s, designe s, and o he impo an s akeholde s, who
a e “expe s o hei expe iences” (Sleeswijk Visse e al., 2005, p. 127).
Co-design has been ound o be e ec i e in he explo a ion o use s’
knowledge (S een, Manscho , & De Konig, 2011; T ischle & Cha les,
2019). Fo he abo emen ioned cha ac e is ics, I chose co-design as a
undamen al app oach o my esea ch along wi h se ice design, and
hus, I will also discuss lea ning o design p ac ices and p ocesses as one
o he key elemen s in my esea ch.
A his poin , le us ake an ini ial look a he oo s o co-design.
The alue o in ol ing bo h end use s and o he s akeholde s as pa o he
design p ocess has inc eased since he 1970s (Sande s & S appe s, 2008),
and i has become inc easingly popula in businesses and o ganiza ions
(Binde , B and , & G ego y, 2008). The ole o use in ol emen has
changed o e he pas ew decades om design o use s o design wi h
and by use s (Sande s & S appe s, 2008). The oles can a y om passi e
engagemen o p oac i e engagemen , whe e use s “con ibu e o sol ing
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
54
and aming design challenges” (Keinonen, 2009, p. 145). Co-design is
connec ed o he ield o pa icipa ion (Lee, 2008) wi h c ea i e coope a ion
ac oss he whole design p ocess (S een e al., 2011). Co-design happens
usually in wo kshops, whe e people in e ac among each o he h ough
design me hods. Wo kshops a e designed so ha hey ha e an impac on
people by shaping he beha io o pa icipan s (Vog , 2009).
Co-design and se ice design ha e many mu ually suppo i e
elemen s. Acco ding o S een e al. (2011), wo di e en pe spec i es a e
needed when combining se ice design and co-design: unde s anding a
se ice’s demand side, which includes use s’ and cus ome s’ needs, and
unde s anding he supply side, which consis s o echnologies and se ice
p ocesses. The au ho s also no ed ha i is impo an o i s iden i y
he goals o he de elopmen p ojec and a ew co-design ac i i ies and
hen associa e and align bene i s o hese goals. Communica ion and
in e ac ions a e no only he undamen als o co-design bu a e also a
cen al pa o e e y se ice (Kuu e e al., 2014). Unde s anding people’s
beha io s and expe iences and he ole o echnologies and ouchpoin s
in holis ic se ice p ocesses is impo an when pa icipan s in co-design
sessions ep esen hei own ields and backg ounds (Alhonsuo, Hookway,
e al., 2020).
All o us can b ing alue o he co-design p ocess by ha ing
p ac ical, local, and ich expe iences o se ices (Kuu e, 2020), bu his
is especially ue o hose who ha e i s -hand knowledge and li ed
expe ience o he se ice. He e, empa hic design is cen e ed wi hin se ice
design s udies, equi ing designe s o ocus mo e on hese eal-li e s o ies
(e.g., Ma elmäki, Vaajakallio, & Koskinen, 2014) and suppo ing a c ea i e
unde s anding (Pos ma, Zwa k uis-Pelg im, Daemen, & Du, 2012).
Acco ding o Ma elmäki and Ba a bee (2002), “Design empa hy is needed
when going om a ional and p ac ical issues o pe sonal expe iences and
p i a e con ex ” (p. 266). This is impo an in he con ex o heal hca e,
whe e people ackle e y sensi i e, pe sonal, and p i a e issues, and i
should also be conside ed in he ea ly phase o se ice design and co-
design p ocesses o ensu e quali y and us in coope a ion. Thus, I also
emphasize he us be ween he pa icipan s, which was also conside ed
in he sub-s udies o his s udy (Figu e 9).
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
54 55
Figu e 9. Building us be ween pa icipan s and c ea ing eam pos e s in design sp in s
(sub-s udies III and IV). (Pic u es: Maileena Tuokko)
Co-design is widely used in he heal hca e domain o unde s and he ield
in e ms o i s bigge pic u e (e.g., Pi inen, 2016; T ischle , Die ich, &
Rundle-Thiele, 2019; Vaajakallio, Lee, K onq is , & Ma elmäki, 2013)
bu also when de eloping speci ic ea men p ocesses (e.g., K onq is ,
Jä inen, & Leinonen, 2013; Pya , Sinclai , & Bibb, 2019). In many
heal hca e- ela ed s udies, expe ience-based co-design (EBCD), o iginally
called expe ience-based design (EBD), is in eg al o co-design and se ice
design, which means ha pa ien s and heal hca e s a ’s expe iences
a e closely conside ed (e.g., Ba e & Robe , 2007; Done o, e al., 2015;
He io , 2018; Robe e al., 2015). In his disse a ion, he inclusion o
pa ien expe iences is only sligh ly discussed, as he esea ch examined he
in ol emen o heal hca e p o essionals in he design p ocess. The esea ch
did no unde es ima e he impo ance o pa ien pa icipa ion bu , a he ,
buil a ounda ion o collabo a ion and unde s anding among heal hca e
p o essionals o make pa ien s mo e in ol ed and welcomed la e in he
design p ocess.
Ne e heless, challenges a e highligh ed and aised o discussion
in co-designing heal hca e ields wi h se ice design. Fo ins ance, how
o deal wi h sensi i e and less engaging cases wi h ulne able use g oups
and how he ele an use s can also ac i ely and equally con ibu e in he
ea ly s ages o he se ice design p ocess ha e been explo ed (T ischle ,
Die ich, & Rundle-Thiele, 2019). Resea che s ha e also in es iga ed how
he co-design p ocess ollowing EBCD equi es heal hca e p o essionals
and pa ien s o enego ia e hei oles and expec a ions and e o m he
ela ionships o powe be ween ci izens and public se ices (Done o e
al., 2015). In his ega d, hey ha e ied o de e mine how o selec he
pa icipan s o co-design wo kshops when sel -selec ing may esul in
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
56
bias and he pa icipan s do no ep esen he desi ed popula ion (Boyd,
McKe non, Mullin, & Old, 2012).
Acco ding o Hakio and Ma elmäki (2011), co-design in public
o ganiza ions migh ace di icul ies ela ed o communica ion be ween
design and heal hca e e minologies, us , and sha ed unde s anding
wi hin he p ojec g oup. They also sugges ed ha he e migh be issues
such as he isk o losing c edibili y o ea ega ding design p ac ices.
The au ho s s essed ha i is ex emely impo an o conside how
design p ac i ione s app oach he o ien a ion phase o co-design and
design me hods. Powe Poin p esen a ions o semina s a e no enough o
in oduce a co-design app oach, and because o his, he e is a need o
mo e hands-on expe ience. They also discussed he impo ance o empa hy
o o he people, such as colleagues, s akeholde s, o use s, as being able
o posi ion onesel in someone else’s si ua ion is he key o ans o ma ion
and change.
Al hough pa ien in ol emen and pa ien expe iences ha e been
emphasized in many o he s udies no ed abo e, in his esea ch, I ha e
b ough o wa d he need o build us be ween ac o s in he design ield
(e.g., se ice designe s, design esea che s, design s uden s) and ac o s
in he heal hca e ield (e.g., doc o s, nu ses, o he expe s). The c i ical
issues men ioned in he p e ious pa ag aph can hen be discussed wi h
pa icipan s in he ea ly phase when he unde s anding o he possibili ies
and p ac ices o se ice design and co-design is clea e . In addi ion,
my esea ch has ound ha he e is a need o pu e o in o os e ing
he lea ning o design hinking and me hods in p ac ice, encou aging
collabo a ion and knowledge-sha ing among he heal hca e p ac i ione s,
and using co-design and se ice design in he ea ly phase o he design
p ocess.
2.3. Heal hca e Se ices
Heal hca e is a complex ield o silo-s uc u ed p ocesses, whe e in e ac ions
among a ious s akeholde s a e elied upon (Bowen e al., 2013), and is a
uni e sally used se ice ha impac s economies and quali y o li e (Be y
& Bendapudi, 2007). Heal hca e is desc ibed as a “ ou ine pa o ou li es,
bu i is o en any hing bu ou ine o he people ecei ing i ” (Goodwin,
2020, p. 37). Ne e heless, heal hca e is a c i ically impo an se ice,
whe e we o en end up unin en ionally, no knowing how much i will cos
o wha will happen. I is an unknown quan i y wi h an unknown du a ion
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
62 63
se ice design handbooks do no o e ips o empla es o doing i .
Benchma king should be conside ed a pa o a con inuous imp o emen
p ocess (Kay, 2007), and om ha poin o iew, i is a aluable p ocess o
se ice design, whe e se ices a e cons an ly e ol ing and ne e “ eady.”
In heal hca e, solid mains eam hospi als a e con inuously using
benchma king o a oid isks, de ec s, and limi ed pa ien sa e y and o
imp o ing quali y (e.g., Lied ke e al., 2017; Rasche, Ma ga ia, & Floyd,
2017). In addi ion, benchma king can be used o in e nal pu poses,
whe e p o essionals collec pe o mance da a and hen benchma k hem
wi h he aim o imp o ing he in e nal cul u e and making clinically
meaning ul quali y changes (Gleason & Bohn, 2017). Gleason and Bohn
(2017) conside i a way o “change he men ali y” (p. 151). A icle 1 o
his esea ch by Mie inen and Alhonsuo (2019) emphasizes ha change
p ocesses need pee - o-pee lea ning, and hus, ans o ma ional change
in o ganiza ional cul u es and a commi men a he managemen le el a e
needed so benchma king can ensu e ha he ou comes o se ice design
p ocesses a e obse able. This also equi es ha all s akeholde s unde s and
how he scaling-up s ep can ake no only inno a ions om expe imen s
o implemen a ion bu also s a egic day- o-day managemen .
As add essed in a icle 2 o his esea ch by Alhonsuo and Colley
(2019), he use o benchma king emains pe haps one o he mos cos -
e ec i e and as es app oaches o a new hospi al o adop gene al bes
p ac ices o pa ien -cen e ed ca e. Ye benchma king as a p ocess seems
o be lacking conside a ion in he se ice design li e a u e. As a possible
p ocess o unde s anding heal hca e se ices a he mic o, meso, and
mac o le els, he e is huge po en ial o de elop ools o benchma king and
e lec he expe ienced p ocesses in a holis ic way, o example, h ough
p o o yping in ole-playing o desk op walk h oughs. I will discuss his
gap la e in my conclusion.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Pic u e: Maileena Tuokko
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
65
3. Resea ch Design
As a esea che , I ha e always been cu ious abou he people a ound me,
and he design ield has p o ided many oppo uni ies o wo k wi h di e en
people. I unde s and he wo ld a ound me be e when I am pa o i in
a p ac ical sense. I lea n by doing, which is he eason why I ha e been
doing my esea ch in design and in a e y p ac ice-o ien ed way. This has
de ini ely guided me on my way while cons uc ing his disse a ion. The
choice o me hodology o his s udy was de ined h ough he objec i es
o ou sub-s udies conduc ed o his wo k. In addi ion, my own p e ious
and ongoing p o essional expe iences as a se ice designe ha e had an
in luence on he selec ed app oaches.
The main objec i e o my esea ch is o desc ibe how se ice
design and co-design app oaches suppo heal hca e- ela ed se ice
de elopmen , especially in he ea ly phase o he design p ocess. The
aim is o answe he esea ch ques ion h ough he ou sub-s udies. The
i s sub-s udy has been published as an academic book chap e and he
o he h ee ha e been epo ed in in e na ional pee - e iewed con e ence
p oceedings. This sec ion will discuss he esea ch design app oach and
i s philosophical ela ionship o he opic. A he end o he sec ion, I
will desc ibe each sub-s udy in de ail, explaining he me hods, da a, and
analyses.
3.1. Resea ch h ough Design
We can see design e e ywhe e a ound us. All en i onmen s, u nishings,
clo hes, echnologies, communica ions sys ems, a i ac s, se ices, and
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
66
p ocesses ha e been designed. The designe ’s ole is o “p oduce e icien ,
e ec i e, imagina i e and s imula ing designs” ha a e based on he
communica ion o a speci ic need o p oposal (C oss, 2007, p. 33). The
de ini ion o design in ol es mul iple in e p e a ions and app oaches.
Design has been seen as ins umen al o p oblem-sol ing (Simon, 1973)
and plan-making (Ri el, 1987). Schön (1987) c ys allized design as an
ac ion whe e he designe is an indi idual who can look a a di e en
complex and incohe en si ua ion, ha e he imagina ion o hink abou
how hings can be done di e en ly, and hen design some hing new ou
o i .
Design p oblems ha e been seen also as “wicked p oblems,” which
a e loosely de ined as p oblems ha a e di icul o impossible o sol e, such
as hose ela ed o heal hca e, quali y o li e, and po e y (Ri el & Webbe ,
1973). He e, “designe s ha e o lea n o ha e he sel -con idence o de ine,
ede ine and change he p oblem-as-gi en in he ligh o he solu ion
ha eme ges om hei minds and hands” (C oss, 2007, p. 24) We can
see complexi ies, needs, a ie ies o design disciplines, and he inc easing
speed o new inno a ion and echnologies a ec ing and challenging design
as i is. Conside able p essu e is pu on designe s because o hei abili y o
design some hing o ally new. Acco ding o Nelson and S ol e man (2012),
we will ne e be able o g ound design on he idea ha he “ igh ”
design is ou he e, embedded in eali y, jus wai ing o be disco e ed.
To he con a y, design will always be abou c ea ing some hing
ha does no ye exis . I is no abou inding some hing al eady in
exis ence. (Nelson and S ol e man, 2012, p. 28)
O e he las ew decades, design esea ch has pu i s oo s down in
academic and heo e ical ields. The e has been esea ch on design p ac ice
o unde s and he p ocesses; esea ch o design o imp o e he esul s;
and esea ch h ough design, which, as he newes di ec ion, “helps o
communica e he na u e o his ela ionship owa d o he academics”
(B edies, 2016, p. 12). The esea ch h ough design (R D) concep , on
which his esea ch is also based, was in oduced by F ayling (1993). La e ,
R D was c i iqued by Zimme man, S ol e man, and Fo lizzi (2010): “We
a gue ha he e is a need o se ious de elopmen o R D in o a p ope
esea ch me hodology ha can p oduce ele an and igo ous heo y” (p.
216). R D alls unde he ub ic o cons uc i e design esea ch (Koskinen,
Zimme man, Bonde , Reds öm, & Wens een, 2011), which also o e laps
wi h his esea ch. When he aim o he esea ch is o de elop a conc e e
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
66 67
plan, ins umen , o p ocess model, and when i comes o c ea ing a new
kind o eali y on he basis o heo ies, exis ing s udies, and esea ch
da a, cons uc i e esea ch is a sui able app oach (Ojasalo, Moilanen, &
Ri alah i, 2015).
Design in public se ices, such as heal hca e se ices add essed in
his esea ch, demands a new o m o design p ac ice, and i is essen ial
o ha e a design esea che as a social expe o such wo k, acco ding o
P ess (2016). P ess also no ed ha “ he dange o se ice design o public
se ices is ha i becomes inco po a ed wi hin he ins i u ional pa adigm
ha i has he po en ial o challenge, and hus becomes jus ano he
echnoc a ic ool o he public sec o ” (p. 25). Mo eo e , acco ding o P ess,
a design esea che as a social expe should a he aim o cons uc social
p oblems h ough design and be ac i ely pa o hem, no aim o sol e
he social p oblems. This uly has connec ions wi hin his esea ch, as I
ac i ely pa icipa ed in he sub-s udies desc ibed he e. By adop ing se ice
design and co-design app oaches and engaging a wide ange o people,
we can oge he aim o econs uc u u e di ec ions o ou socie ies. By
adap ing esea ch h ough design in my own s udy, I s eng hened he
link be ween se ice design p ac ice and design esea ch. The p ac ical
amewo ks o heal h- ela ed de elopmen we e, hus, c ea ed du ing he
esea ch.
Figu e 11 is adap ed om he illus a ion by Saunde s and Tosey
(2012), which is he me apho o he “Resea ch Onion.” I p o ides an
o e iew o my esea ch design, ep esen ing he elemen s ha need o
be conside ed in ela ion o o he design elemen s. These elemen s a e
desc ibed in de ail in he ollowing subsec ions.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Pa adigm
S a egies
Me hods
Da a
Analysis
Cons uc i ism
Quali a i e esea ch
E hnog aphic s udies
Case s udies
Con en analysis
Wo kshops
In e iews
Resea ch dia ies
Field no es
68
Figu e 11. O e iew o he s udy. (Au ho ’s illus a ion)

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
68 69
3.2. Cons uc i ism
The wo ld iew o his esea ch is based on cons uc i ism, also known
as in e p e i ism and social cons uc i ism. A wo ld iew is “a gene al
philosophical o ien a ion abou he wo ld and he na u e o esea ch ha
a esea che b ings o s udy” (C eswell, 2014, p. 6). In cons uc i ism,
a eali y is socially cons uc ed and indi iduals engage wi h hei wo ld
in an a emp o unde s and he wo ld in which hey li e and wo k. The
esea che aims o lis en o and unde s and people and us he iews o
mul iple pa icipan s h ough language, and hen in e p e s he indings
in a p ocess shaped by he expe ience o he esea che (C eswell, 2014).
In se ice design esea ch, cons uc i ism is one o he mos commonly
used epis emologies (Sun, 2020) and heo ies in p ac ice (Yang & Ge gen,
2012). Cons uc i ism is ypically cha ac e ized by an induc i e app oach
o esea ch, whe e he esea ch s a s in eal-wo ld se ings and con ex s
and in which empi ical da a a e ga he ed. Then he esea che s in e p e
he da a, leading o he de elopmen o heo ies and, hus, he cons uc ion
o knowledge.
Cons uc i ism is closely ela ed o lea ning, whe e lea ning is seen
as an ac i e p ocess o cons uc ing knowledge, and h ough his, making
sense o he wo ld (Adams, 2003). The common elemen o all a ie ies o
cons uc i is heo ies is “ he na u e o he lea ning en i onmen is one
o expe imen a ion and dialogue, whe e knowledge is seen wi hin he
con ex o p oblems o be discussed and sol ed” (Adams, 2006, p. 245).
He e, he lea ning is a social p ocess (Shepa d, 2000), and in my esea ch,
i happened h ough co-design p ac ices and wo kshops. Acco ding o
C eswell and C eswell (2018), as a esea che , I am ac i ely pa o he
esea ch and in luence he in e p e a ion o he phenomenon h ough
my own backg ound and pe spec i es. This uly has an impac on he
esea ch p ocess, whe e I can choose he opic and p oblem o he esea ch
and o mula e he esea ch ques ions and me hods (C o y, 1998). In
addi ion, cons uc i ism elies on a quali a i e esea ch amewo k, which
is also used in o ganiza ional esea ch and o ganiza ional change (Doldo ,
Sil es e , & A ewologun, 2017).
F om an on ological pe spec i e, which is de ined as a conside a ion
o being and wha is and wha exis s (Packe & Goicoechea, 2000),
cons uc i ism has mul iple pe spec i es and eali ies. “Reali ies” in his
iewpoin we e de ined by Guba and Lincoln (1994):
[Reali ies a e] app ehendable in he o m o mul iple, in angible
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
70
men al cons uc ions, socially and expe ien ially based, local and
speci ic in na u e (al hough elemen s a e o en sha ed among many
indi iduals and e en ac oss cul u es), and dependen o hei
o m and con en on he indi idual pe sons o g oups holding he
cons uc ions. (Guba and Lincoln, 1994, pp. 110–111)
Acco ding o Bisman and High ield (2012), eali y is c ea ed by he mind.
They a gued ha di e en social o ganiza ions, cul u es, and expe iences
can c ea e se e al social eali ies. They poin ed ou , howe e , ha wha is
eal is speci ic o an indi idual, and he e migh be simila i ies be ween
indi iduals and g oups o indi iduals in unde s anding wha is eal.
3.3. Resea ch S a egies and Me hodological Choices
I used a quali a i e esea ch s a egy wi h e hnog aphy and case s udy
as my me hodological choices. Resea ch o his ype uses an induc i e
app oach, whe e esea che s s a wi h a eal-wo ld se ing and ga he
empi ical ma e ials om case s udies. A e his come he in e p e a ion
and e lec ions wi h a hypo hesis and heo y. Quali a i e esea ch
ollows an induc i e design, whe e meaning ul and desc ip i e da a
a e gene a ed (Lea y, 2017). This is in-dep h esea ch, whe e he aim is
o collec di e en o ms o da a om di e en sou ces and in es iga e
hem om many di e en pe spec i es (Mu a o ski, 2015). Acco ding o
Leedy and O mo od (2010), quali a i e esea ch i s bes o desc ibing,
in e p e ing, and e i ying opics. I is ideal o unde s anding se ings,
p ocesses, ela ionships, o people, which ings ue wi h his s udy. In a
se ice design se ing, co-designing wi h people is c ucial. E en hough
he de eloped opics a e ela ed o se ices and p ocesses, hey ie people
and hei ela ionships oge he and help o cla i y use expe iences.
Se ice design me hods and ools aim o unde s and use expe iences and
he s o ies behind hem h ough open-ended, na a i e, and isual ways,
whe e pa icipan s can sha e hei iews and opinions eely.
Case S udies
Case s udy app oaches we e used as a esea ch s a egy in sub-s udies I,
III, and IV. The case s udy is a quali a i e esea ch amewo k wi h a se
o ools o da a collec ion ega ding complex phenomena (Bax e & Jack,
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70 71
2008), and i is linked o he cons uc i is pa adigm (S ake, 1995). The case
s udy app oach enables mul iple le els o analysis om a single s udy (Yin,
2009), which can be a p og am, ac i i y, p ocess, o indi idual(s) (C eswell,
2014). Acco ding o Yin (2014), case s udy as a esea ch app oach should
be conside ed in si ua ions when he esea ch ocus is on answe ing “how”
and “why,” as ele an beha io canno be manipula ed by hose who a e
in ol ed in he s udy, and he s udy unde in es iga ion is con empo a y.
In an explo a i e way, case s udies gi e an in-dep h unde s anding o a
eal-li e con ex , which i s well in he se ice design ield.
In gene al, case s udies a e c i icized o lacking igo and no
ollowing sys ema ic p ocedu es, being di icul o gene alize, and aking up
oo much ime while p oducing la ge amoun s o in o ma ion (Yin, 2014).
I was ob ious ha du ing he case s udies, he o ms o da a collec ion
and p ocedu es changed o be e sui he si ua ions and en i onmen .
Consequen ly, in some cases, he amoun o da a inc eased bu was no oo
o e whelming o ake in o accoun . I should also be no ed ha in hese
case s udies, he phenomenon was heal hca e- ela ed p ocesses in he
hospi al con ex , whe e di e en s akeholde s co-design using di e en
design me hods.
E hnog aphic S udies
P e iously, I in oduced a case s udy app oach ha has some simila i ies o
e hnog aphic s udies. E hnog aphic s udies aim o ob ain a holis ic pic u e
o he opic unde in es iga ion and engage indi iduals and unde s and
hei e e yday expe iences by in e iewing and obse ing hem (C eswell,
2014). E hnog aphy, which Lea y (2017) desc ibed as “a w i en ex
abou cul u e” (p. 259), s udies social in e ac ions, people’s beha io , wha
hey belie e, and o he pe cep ions ha appea wi hin communi ies,
o ganiza ions, and g oups (Mu a o ski, 2015). Bo h se ice design and
e hnog aphic s udies aim o p o ide holis ic insigh s in o di e en cul u es,
which Mu a o ski (2015) de ined as “people’s iews and ac ions” (p. 56).
Also unde in es iga ion a e he elemen s o he en i onmen a ound
hem, including he sounds, sigh s, and loca ions, which can be linked as
ouchpoin s, acco ding o se ice design li e a u e. Se ice ouchpoin s a e
angible objec s o spaces (Mo i z, 2005) in he line o in e ac ion be ween
he cus ome and se ice p o ide , o hey a e in angible elemen s, such
as sounds, smells, and empe a u e. The se ice ouchpoin s a e a ound
us in di e en se ice momen s and ha e an o e all impac on how we
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72
expe ience hese momen s. The se ice ouchpoin s a e impo an o
ecognize in e hnog aphic s udies.
E hnog aphy in he con ex o design is embedded in i e a i e
design p ocesses, is sho - e m and quick in i s du a ion (Mülle , 2021),
and can o e nume ous op ions o dealing play ully wi h collec ed da a,
which equi es no only explica ion and e lec ion bu also discipline
(Mülle , 2020). In design e hnog aphy, “i is pe mi ed o bu s open
con en ions, explo e bounda ies and expand cogni i e ho izons. (…)
Design e hnog aphy can mean obse ing social si ua ions passi ely in
o de o change hem a e wa ds h ough in e en ions, hen obse ing
he esul s again, and so on” (Mülle , 2020, p. 227). As in my esea ch, he
esea ch p ocess o design could change unexpec edly. In i , he esea che ’s
ole is o adap du ing he p ocess and be c ea i e, e en play ul, o be e
unde s and elemen s o he en i onmen , o example.
Ne e heless, e hnog aphy emphasizes h ee key elemen s ha
esea che s need o conside : ype o communica ion, le el o in eg a ion,
and du a ion o he s udy (Mu a o ski, 2015). The i s elemen , ype o
communica ion, is c ucial in esea ch done in he heal hca e ield, whe e
my pe sonal mo i a ion o conduc ing he s udy alone was no enough.
F om my expe ience, he e needs o be a clea in oduc ion o wha is
going o happen, how i is done, and wha i s alue is o pa icipan s.
In he heal hca e con ex , p o essionals om he hospi al gi e hei ime
o he p ojec , and he hospi al lacks esou ces while he p o essionals
a end a wo kshop. I he communica ion is unclea , i is di icul o engage
hem. In addi ion, he ype o communica ion is c ucial du ing he s udy
especially when expe s om a ious heal hca e p o essions in he hospi al,
pa ien s o di e en ages wi h di e en backg ounds and diseases, and I
as a designe mee . The second elemen , le el o in eg a ion, e e s o he
esea che being ei he an “ou side ” o “inside ,” as Mu a o ski (2015)
explained. An expe ienced esea che knows when o be a silen obse e
o in e iewe and when hei ole should be mo e ac i e and engaging.
Rega ding he hi d elemen , du a ion o he s udy, especially
in heal hca e- ela ed co-design wo kshops, he e needs o be enough
ime o hinking h ough complex scena ios, expe iences, and se ice
p ocesses. This has been a huge lea ning poin o me as a esea che ,
whe e a pe iod o silence is no always a momen o igno ance o e en
o unconsciousness. I is usually a momen o in-dep h hinking and
p ocessing—and some imes, i exe s posi i e p essu e ha pushes people
owa d dialoguing. In he pas , i was common o engage in e hnog aphy
as a long- e m commi men , bu ha has changed, and i is cu en ly mo e
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Design p obe Design p obe Design p obe
1. wo kshop 2. wo kshop 3. wo kshop
78 79
he de elopmen o he hospi al’s ope a ions, and why?”; “Wha did he
benchma king si e isi s p o ide o he g oup?”; “How would you de elop
benchma king wo k i sel ?”; “How did you apply lean/huddle in you
own wo k a e he ip?”; “Wha kind o expe iences ha e he e been?”;
and “How did benchma king open up ecosys em hinking om a se ice
pe spec i e?” These da a we e ansc ibed and analyzed ia a quali a i e
con en analysis me hod.
Case S udy 2: Rehabili a ion P ocesses o Child en Li ing in Lapland
The second case s udy ocused on examining and de eloping exis ing
child en’s ehabili a ion p ocesses and ecosys ems in he eigh municipali ies
o Lapland. The case s udy was conduc ed om Feb ua y 2017 o June
2017 and was pa o a p ojec called C i ical Communica ion, Sa e y and
Human-Cen e ed Se ices o he Fu u e (CRICS). S ong collabo a ion
was done wi h Lapland Cen al Hospi al, especially wi h he child en’s
depa men . The hospi al coo dina ed he case s udy pa icipan s because
hey had con ac s wi h heal hca e p o essionals in he municipali ies.
These p o essionals we e doc o s, nu ses, di e en he apis s, such as
physio he apis s and speech he apis s, neu opsychologis s, and social
wo ke s. Pa icipan s in he case s udy used se ice design ools o
isualize he exis ing heal hca e ecosys em su ounding municipali ies’
ehabili a ion acili ies and o ackle local challenges in his p og am. The
aim was o de elop new solu ions o be e and mo e e icien se ices
ha can p o ide equal heal hca e o all amilies and hei child en in his
emo e egion. The case s udy was conduc ed in h ee wo kshops and
h ee design p obes (Figu e 13).
Figu e 13. The esea ch p ocess in case s udy 2: Rehabili a ion p ocesses o child en
li ing in Lapland.

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80
Design p obes a e de ined as use -cen e ed and design-o ien ed sel -
documen a ion ools whe e he aim is no only o unde s and human
phenomena and design oppo uni ies (Ma elmäki, 2006) bu also o
“pu pose ully in i e o p o oke use s o e lec on and e balize hei
expe iences, eelings and a i udes, and o isualize hei ac ions and
con ex s.” (Ma elmäki, 2005, p. 83). As a me hod, i ac i a es pa icipan s
in a play ul and c ea i e way o collec explo a o y and pe sonal da a. The
p obes a e widely used as a design me hod, and acco ding o Ma elmäki
(2005), hey can be p esen ed in ou di e en se ings: cul u al p obes
(Ga e & Dunne, 1999), in o ma ional p obes (Hemmings, C ab ee,
Rodden, Cla ke, & Rounce ield, 2002), echnology p obes (Hu chinson e
al., 2003), and empa hy p obes (Ma elmäki & Ba a bee, 2002).
This s udy u ilized p obes as an in o ma ion ga he ing me hod
ins ead o ying o speci ically unde s and how people we e eeling.
The aim o he i s p obe was o collec da a on exis ing esou ces,
needs, and challenges. The p obe was a ques ionnai e in pd o ma wi h
yping op ions. I was sen o municipal heal hca e p o essionals wi h
an in oduc ion. They could ill ou he ques ionnai e on a compu e o
p in i ou , handw i e i , and scan o send i ia he pos . We ecei ed
25 esponses. The answe s we e ansc ibed in o Excel and hen in o an
expansi e p in ed empla e, which we called he esou ce bluep in . The
isualized esou ce bluep in was used in he i s wo kshop, and i p o ed
o be c ucial h oughou he whole p ojec . I wo ked as an in o ma ion-
sha ing pla o m and opened up he discussion be ween p o essionals.
I was also c ucial o explaining he se ice ecosys em amewo k o all
eigh municipali ies.
The i s wo kshop was held in Ro aniemi wi h 24 pa icipan s.
The aim o he wo kshop was o unde s and he esou ces, needs, and
challenges in child en’s ehabili a ion p ocesses in Lapland. Da a om he
ques ionnai es and esou ce bluep in we e used and supplemen ed bu
no inalized. The wo kshop was e y dialogue- ocused and achie ed wo
objec i es: ag eemen on de ini ions o pe cei ing child en’s ehabili a ion
in Lapland and concluding six de elopmen challenges. The la e
was gene a ed in a o m o mind map in small g oups. The da a we e
documen ed in pic u es and ansc ibed in o Excel.
The second design p obe was a ques ionnai e wi h nine esponses.
The aims we e o seek di e en solu ions o ideas o mo e adap i e
se ices in ehabili a ion. Ques ion examples om he p obe conce ned
how o enable he ac i e oles o he child and he amily in ehabili a ion
(planning, implemen a ion) and o hink o ways o make ( ehabili a ion)
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80 81
se ices easily accessible o amilies. We also wan ed o unde s and he
ex e nal esou ces, o example, in schools o hobbies and how we could
u ilize hose in ehabili a ion p og ams. In addi ion, he Lapland Cen al
Dis ic sen ques ionnai es o amilies, who we e hei exis ing o pas
cus ome s, and asked o eedback on and de elopmen ideas o hei
se ices. Thi y ques ionnai es we e sen and 11 eplies we e ecei ed. The
da a om he design p obe and ques ionnai e we e hemed and p esen ed
in he ollowing wo kshop.
In he second wo kshop, da a om he p e ious p obes and
ques ionnai es we e p esen ed and discussed wi h 22 pa icipan s. The
main objec i e o he wo kshop was o c ea e a se ice jou ney ha
isualized six main phases: (1) wo ying, (2) con ac ing a se ice p o ide ,
(3) assessing he child’s unc ional capaci y, (4) c ea ing a ehabili a ion
plan, (5) implemen ing he plan, and (6) con olling and assessing
ehabili a ion esul s. This isualized p ocess suppo ed pa icipan s in
de ining he en i e ehabili a ion p ocess and unde s anding he mos
impo an needs in ol ed.
The hi d design p obe was done wi h he Google Fo ms
ques ionnai e ool, u ilized he c ea ed se ice jou ney, and deepened
he in e nal p ocesses in each o he six phases. We asked p o essionals
o highligh such aspec s as who is pa o he phase, whe e i happens,
how i happens, and wha kind o minimum iable se ice/p oduc would
be sui able in his phase. In addi ion, he ques ionnai e included ideas
al eady c ea ed, and we asked pa icipan s o o e on he bes ideas. The
mos o ed o ideas we e p o o yped in he las wo kshop. We collec ed
15 eplies om he online inqui y.
The las wo kshop summa ized he whole case s udy. The aim was
o p o o ype and ole-play he mos o ed- o ideas wi h 26 heal hca e
p o essionals. Two scena ios we e selec ed and he pa icipan s ook on
di e en oles, such as mom, dad, child, eache , nu se, and physio he apis .
The wo kshop was ideo eco ded and i e a ed se ice scena ios we e
isualized as s o yboa ds.
The se ice design ou comes o case s udy 2 we e h ee isualized
se ice concep pic u es (Figu e 14), which we e p esen ed in a subsequen
heal hca e semina . The i s se ice concep was a digi al pla o m o
p o ide di e en ehabili a ion se ices o amilies wi hou a doc o ’s
e e al. This idea would enable amilies o, o example, use i ual
eali y as a new way o mo i a e child en wi h mo emen s. The second
se ice concep was a digi al se ice allowing a mul i-p o essional eam
o mee amilies quickly and easily wi hou long jou neys and scheduling
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
82
challenges. The se ice i s would de e mine whe e he challenges a e,
on he basis o which he sys em can selec he igh p o essionals. The
sys em would c ea e a sepa a e dia y o he child, enabling he amily and
p o essionals o ollow he ehabili a ion as a se ice pa h, see pas and
u u e appoin men s, and compile a ehabili a ion plan. The sys em would
allow o seeing how he child has de eloped du ing he ehabili a ion
p ocess. Pa en s could also in e ac wi h expe s ia cha , i needed. The
hi d se ice concep , School as pa o ehabili a ion, was de eloped
as a suppo se ice o eache s in schools ha would enable eache s
o con ac a neu opsychia ic coach and ask o suppo and assis ance
du ing eaching. A neu opsychia ic coach would p o ide men al suppo
o a child o adolescen in coping wi h e e yday challenges using hei
own s eng hs. Thus, he in eg a ion o he eache in o ehabili a ion was
deemed impo an .
Figu e 14. Examples o isualized se ice concep s c ea ed o amilies and heal hca e
p o essionals du ing he case-s udy 2 in sub-s udy I. (Au ho ’s illus a ion)
1. Se ice concep
3. Se ice concep
2. Se ice concep
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
82 83
3.4.2. Sub-S udy II
The second sub-s udy in es iga ed pa ien s’ expe iences o he design
p ocess o new hospi als, especially co-design me hods including pa ien s.
I was especially cu ious o s udy he p e-cons uc ion phase o new hospi al
design, whe e changes may be mo e easily inco po a ed and pa ien
oices included. The a icle was a sho pape ha aimed o alida e and
ex end exis ing discussions on he challenges, needs, and good p ac ices
o applying pa ien -cen e ed co-design me hods. The pape desc ibed he
co-design me hods in wo new hospi al builds h ough semi-s uc u ed
in e iews, which I o ganized wi h h ee expe s in wo hospi als. In
addi ion, I obse ed a co-design wo kshop be ween hospi al s a and
hospi al a chi ec s in one o he hospi als. The in e iews and obse a ions
we e done in 2018.
The in e iew ques ions aimed o cla i y he big pic u e o a new
hospi al design p ocess, especially he p e-cons uc ion pa . The ques ions
consis ed o ou main hemes: (1) planning phases o new hospi al design,
(2) he s akeholde s who we e in ol ed and why, (3) wha me hods and
ools we e used in which phases, and (4) how pa ien s pa icipa ed in he
design and decision p ocesses. I aimed o ge a deepe unde s anding
o wha wo ks and wha does no . The in e iews we e eco ded and
ansc ibed. I used an a ini y diag amming app oach o iden i y he main
hemes om he da a.
The co-design wo kshop be ween hospi al s a and hospi al
a chi ec s in one o he hospi als ocused on he ca diology wa d. I
obse ed he wo-hou -long session, whe e an a chi ec , ou nu ses,
and wo doc o s discussed he loo plan o he wa d. They ocused, o
example, on he wai ing and pa ien a eas in he wa d. I mainly obse ed
how he pa ien s we e being conside ed du ing he discussion and how
he se ices we e conc e ized in he wai ing and pa ien a eas. I ook no es
du ing he wo kshop and added he da a in o he a ini y mapping used in
in e iews.
3.4.3. Sub-S udies III and IV
Sub-s udies III and IV we e conduc ed h ough h ee heal h- ela ed design
sp in s in he o m o case s udies. These we e held in h ee di e en
loca ions: Go henbu g, Sweden; Tallinn, Es onia; and Ro aniemi, Finland.
The design sp in s we e pa o he esea ch p ojec called Co-designing
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
84
Heal hca e, which was a wo-yea join ini ia i e o highe educa ion
and heal hca e ins i u ions o he h ee abo emen ioned coun ies. The
p ojec had h ee main aims: o a ac mo e designe s o he heal hca e
sec o , o encou age mo e heal hca e p o ide s o use “design as p ocess”
and “design as s a egy,” and o de elop mo e digi al heal h solu ions ha
suppo new o ganiza ion, p ocess, and paymen models in heal hca e.
The p ojec s a ed in No embe 2018 and ended in Decembe 2020.
The pa icipan s who suppo ed he p ojec in Sweden we e
om he Uni e si y o Go henbu g, HDK-Valand; Academy o A and
Design, Sahlg enska School o Inno a ion and En ep eneu ship (SSIE);
Sahlg enska Academy School o Medicine; and Sahlg enska Uni e si y
Hospi al and Child en’s Heal h Cen e Se ices. Those om Es onia we e
om he Es onian Academy o A s, Connec ed Heal h Clus e , and No h
Es onia Medical Cen e, and hose om Finland we e om he Uni e si y
o Lapland and Lapland Cen al Hospi al. The collabo a ion among
academics was s ong du ing he p ojec , and i suppo ed and encou aged
esea ch mobili ies o he s uden s and s a .
The design sp in s in each loca ion a ied. The local hospi al o
heal h cen e ga e a b ie o he design sp in , and he planning and
scheduling we e done by he local eam. The design me hods used in each
loca ion we e also di e en ia ed by he numbe o pa icipan s, b ie s,
and acili ies. A concise o e iew o he espec i e design sp in s, da a
collec ion, and pa icipan s is discussed in he ollowing pa ag aphs.
Case S udy 1: Design Sp in in Go henbu g, Sweden
The ou -day design sp in in Go henbu g was conduc ed in Ap il 2019.
Pa icipan s in he design sp in s we e 18 s uden s wi h in e na ional and
mul idisciplina y backg ounds and ou hospi al ep esen a i es. Two o
he hospi al s a we e wo king in Child Heal h Cen e (BVC) Se ices,
and wo o he s we e om he No h Es onia Medical Cen e. The design
b ie was o imp o e communica ion be ween nu ses and pa en s in BVC
Se ices. In Sweden, child en pa icipa e in BVC Se ices om bi h o he
age o 6 yea s. The e we e wo ocus a eas: in o ma ion on he di e en isi s
du ing he child’s ime a BVC, and in o ma ion in ega d o p epa ing o
a isi ( he child’s pe spec i e). As an ou come o he h ee design sp in
eams, communica ion ools, such as “Cha box” and a “Yea book,” we e
c ea ed o enhance he in e ac ion be ween pa en s and p o essionals. The
ideas we e gi en o BVC bu we e no ye implemen ed.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Design sp in
eam:
18 s uden s
4 nu ses
Idea ion
Concep
de elopmen
Tes ing
C ea ing
ideos
P esen a ions
Field esea ch
Collec ing &
isualising
insigh s & da a
Clus e ing
insigh s & da a
P esen ing
p e ious
cases
In oduc ion
Team building
B ie ing
Men o ing by
E hno s a ion -
in e iews
9 esea ch
dia ies
Go henbu g,
Sweden
A he campus
Pa icipan s:
A he campus A he campus A he campus
Da a:
Men o s:
2 nu ses
1 pa en
Facili a o s:
4 om
design ield
Field
no es
Uns uc u ed
in e iews
84 85
The design sp in p ocess ollowed simple s eps using a design
p ocess s a ing om an in es iga ion and ield wo k, mapping down he
da a o de ine he design challenges, and hen con inuing o he solu ion
h ough idea ion and p o o yping. Figu e 15 summa izes he design sp in
p ocess and he design me hods used in Go henbu g each day.
Figu e 15. Design sp in p ocess in Go henbu g, Sweden.
Da a om he design sp in in Go henbu g we e collec ed h ough esea ch
dia ies, ield no es, and uns uc u ed in e iews. The esea ch dia ies we e
sen ia email igh a e each design sp in day. The ques ions (4 a ied
ques ions pe day) conside ed a ious opics, o example, “Wha kind o
design me hods we e used du ing a design sp in day, and how did he
me hods wo k in you case?”; “Which me hods helped o unde s and he
case be e ?”; “Wha kinds o me hods would ha e wo ked be e o cap u e
he needs o d eams o pa en s and/o child en?”; “How did you hink he
design sp in concep would wo k in heal h- ela ed se ice de elopmen ?”;
and “Wha a e some o he e lec ions, expe iences, o hough s o he
day?” We ecei ed nine eplies in o al. The esea ch dia ies appea ed o be
oo i ing o he design sp in pa icipan s o w i e in a e in ensi e days.
I ook ield no es du ing he design sp in , and I con inually obse ed he
pa icipan s, design me hods used in he design sp in p ocess, and he
en i onmen and acili ies o e ed o he eams. I did isual and w i en
no es om he ield, whe e I highligh ed each design me hod used in he
design sp in p ocess and he eams’ hough s abou he me hod. I also
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86
made no es du ing he uns uc u ed, ad hoc in e iews when asking
pa icipan s speci ic ques ions, such as how he in ensi e days could be
done be e o each he bes heal hca e- ela ed in o ma ion and wha he
pa icipan s el was mos di icul du ing hei mos in ensi e days.
Case S udy 2: Design Sp in in Tallinn, Es onia
The second design sp in was held in Tallinn in Ap il 2019. I was a i e-
day-long design sp in done in collabo a ion wi h No h Es onia Medical
Cen e (PERH), ER/T auma, Day Su ge y, S oke and Ce eb o ascula ,
and Pallia i e Ca e uni s. The design sp in was pa o he bigge se ice
design cou se a he Es onia Academy o A s (EKA) and Tal ech.
Local s uden s o EKA had al eady s a ed hei explo a o y esea ch in
Feb ua y, bu he ac ual design sp in p ocess was implemen ed in Ap il.
Then 19 s uden s om mul idisciplina y ields and one om a heal hca e
backg ound joined a pop-up design s udio in he lobby o he No h
Es onia Medical Cen e and challenged hemsel es in i e eams one o
he ollowing i e hemes: (1) making he p e- isi p ocess aluable; (2)
leading a meaning ul li e a e a s oke; (3) day su ge y cen e ; (4) dea h
wi h digni y; and (5) eme gency depa men (ED) pa ien s’ s ess and
anxie y. The concep ual solu ions we e co-designed in each o he i e
eams, and he local s uden s con inued he de elopmen a e he design
sp in when hei cou se ended in he summe .
The design sp in eams i s amilia ized hemsel es wi h he
exis ing da a, which he local s uden s had ga he ed and isualized o
huge pape -based can ases du ing he i s ew mon hs o he cou se.
Nex , he eams ollowed he basic s uc u e o he design p ocess, s a ing
om he si e isi s, deepening he unde s anding wi h men o ing ounds,
building ough p o o ypes and/o desk op walk h oughs om he ideas,
and inally, es ing, e alua ing, and i e a ing he concep s be o e he inal
p esen a ions. The design sp in in Tallinn o e ed an oppo uni y o
u ilize he heal hca e p o essionals and expe s as isi ing men o s du ing
hei in ensi e wo k. Visi ing men o s we e om he hospi al IT, quali y
managemen , communica ion, se ice, and clinical ields. The s uden s
could ask ques ions and ga he in o ma ion om he expe s om speci ic
ields, hus a oiding any con usion o o he di icul ies du ing he sp in .
Figu e 16 summa izes he design sp in p ocess in Tallinn in mo e de ail.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Design sp in
eam:
19 s uden s
1 nu ses
15 esea ch
dia ies
Tallinn,
Es onia
Pa icipan s: Da a:
Men o s:
12 specialis s
om local
hospi al
Facili a o s:
3 om
design ield
Field
no es
Uns uc u ed
in e iews
Team Can as:
eam membe s
and cla i ying
he opic
S o yboa d
Si e- isi s
Men o ing
P esen a ionsMen o ing
Tes ing,
e alua ing
and i e a ing
Rough p o o-
yping and ole-
play h ough
desk op
walk h ough
Men o ing
In oducing
i e challenges
C ea ing eams
A he hospi al A he hospi al A he hospi al A he hospi al A he hospi al
86 87
Figu e 16. Design sp in p ocess in Tallinn, Es onia.
The da a collec ed om he design sp in in Tallinn included 15 esea ch
dia ies om he pa icipan s, my own ield no es, and uns uc u ed
in e iews. The esea ch dia y was an A5-size bookle wi h p omp s such
as “3 good hough s om oday,” “2 ques ions which a ose o you,” “1 idea
you’ll pu in o p ac ice,” “3–5 keywo ds o illus a e you eam’s p ocess
oday,” and “o he e lec ions, expe iences, o hough s which you eel a e
ele an o say.” The esea ch dia y wi h he p omp s was c ea ed by he
leade o he design sp in acili a o s om EKA, who also wo ked as he
main acili a o s in his design sp in .
The uns uc u ed, ad hoc in e iews we e done in he same way
as in Go henbu g. I obse ed he design sp in p ocess and eamwo k
and asked ques ions, such as “How did you eel ha he men o ing ound
suppo ed you las ime?”; “Wha would ha e wo ked as a be e me hod
o app oach o each he unde s anding in you design b ie ?”; and “How
would you compa e he p os and cons in his design sp in e sus he
p e ious one in Go henbu g?” The las ques ion was asked o he s uden s
who had also pa icipa ed in he design sp in in Go henbu g. I eco ded
ield no es du ing he design sp in using an obse a ion s yle e y simila
o he one I had used in Go henbu g. I obse ed he pa icipan s, design
me hods used in he design sp in p ocess, and he en i onmen and
acili ies o e ed o he eams. I did isual and w i en no es om he ield,
whe e I highligh ed each design me hod used in he design sp in p ocess
and he eams’ hough s abou he me hod.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Design sp in
eam:
6 s uden s
4 esea ch
dia ies
Ro aniemi,
Finland
Pa icipan s: Da a:
Men o s:
2 nu ses
2 om o he
ields
Facili a o s:
1 om local
hospi al
2 om design
ield
Field
no es
Uns uc u ed
in e iews
A he hospi al A he hospi al A he hospi al A he campus A he campus
C ea ing
ideos
P esen a ions
Clus e ing ideas
Vo ing
S o yboa d
P o o yping
chosen idea
Tes ing
Clus e ing
insigh s & da a
Idea ion
Field esea ch
Mapping
down indings
Men o ing
B ie ing
Team building
Tes jou ney
88
Case S udy 3: Design Sp in in Ro aniemi, Finland
The las design sp in was o ganized in Ro aniemi a he beginning o May
2019. I was a i e-day-long p ocess wi h wo eams o h ee in e na ional
s uden s. The aim o he design sp in was o in es iga e and de elop a
ca e and ea men ese a ion cen e a Lapland Cen al Hospi al. Due
o he long a el dis ances in he Lapland a ea, he b ie was di ided
in o wo case s udies. The i s eam conside ed a pa ien who li ed a
om specialized heal hca e ins i u ions, in U sjoki, which is 450 km om
Ro aniemi, whe e he specialized heal hca e is p o ided. The second eam
ocused on a pa ien who li ed in he Ro aniemi a ea, nea he cen al
hospi al, bu was busy wi h seasonal wo k and amily li e. The eams
de eloped heal hca e se ices, such as a LAPP LAB se ice bus o ake
heal hca e se ices and e-heal h solu ions in o u al a eas and a web-based
se ice sys em o make he ea men ese a ion p ocess mo e lexible by
allowing pa ien s o book, change, and cancel appoin men s.
The design sp in p ocess s a ed wi h in oducing he b ie and
doing he ield wo k. The indings we e mapped down, and unde s anding
was deepened h ough men o ing ( wo nu ses om he hospi al and wo
o he expe s om he design/heal hca e ields). Then he eams idea ed
di e en solu ions and use - es ed he selec ed ideas h ough p o o yping.
The inal concep s we e ilmed as a concep ideo. Figu e 17 p o ides a
de ailed p ocess desc ip ion.
Figu e 17. Design sp in p ocess in Ro aniemi, Finland.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
4. Resul s
94 95
4.1. Se ice Design Tools as Suppo ing and De eloping
Hospi al Managemen P ac ices
The la ge da ase om sub-s udy I is in oduced in he ollowing
subsec ions. He e, I will answe he esea ch ques ion: How can se ice
design ools and collabo a i e p ac ices be used o suppo and de elop
cus ome jou neys and hospi al managemen p ac ices? The esul s can
be ca ego ized in o wo a eas. Fi s , I will desc ibe how benchma king
as a ool in he design p ocess can suppo he de elopmen o hospi al
managemen p ac ices, and second, I will in oduce he design me hod
as a way o c ea e and sha e a ision and unde s and ecosys ems in he
heal hca e con ex .
4.1.1. Benchma king as a P ocess o De elop Hospi al Managemen
P ac ices
Benchma king is a widely used p ocess in he heal hca e ield, and i can
be seen as an i e a i e app oach in he de elopmen o heal h- ela ed
se ices (e.g., Kay, 2007; Wes , 2021). I has alue because i helps o a oid
isks, de ec s, and limi s o pa ien s’ sa e y and can be used o imp o e
se ice quali y (Lied ke e al., 2017; Rasche e al., 2017). In sub-s udy I, he
mos signi ican e ec s o benchma king we e ela ed o e idencing he
de elopmen o lean managemen and “ ue no h” hinking, which was
he main objec i e o he case s udy 1. E idencing is needed o decision-

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
96
making a he o ganiza ional and design le els, as i helps o d i e lea ning
and ans o ma ion o wa d (Foglieni e al., 2017). Acco ding o F y
(2019), e idence is impo an when new se ice p ocesses and p ac ices
a e in oduced in hospi als.
Sub-s udy I de e mined ha h ough benchma king, we can ensu e
he quali y, e ec i eness, and imely a ailabili y o se ices and p o ide
e idence h ough examples in he hospi al con ex . Benchma king has i s
alue and con ibu ion when agile expe imen s and e alua ion p ac ices
a e elabo a ed, making i pa icula ly sui able o he agile de elopmen
o a design sp in (Knapp e al., 2016). Benchma king was seen as a way
o lea n mo e abou hospi al managemen p ac ices based on lean, agile,
and human-cen e ed app oaches. In addi ion, in sub-s udy II, we ound
ha benchma king was expe ienced as one o he as es and mos cos -
e ec i e app oaches o a new hospi al’s p e-cons uc ion phase, whe e he
bes p ac ices o pa ien -cen e ed ca e mus be obse ed and in es iga ed.
Sub-s udy I s essed ha he challenge o de eloping he
benchma king i sel was s a egically impo an and ha he e is a ue
need o adop new p ac ices o e ine a benchma king p ocess especially
in he se ice design ield. As highligh ed in he heo e ical backg ound
o his esea ch in subsec ion 2.3.2, he exis ing p ac ical handbooks o
se ice design do no o e ools o empla es o benchma king. Thus,
implemen a ions o and commi men o new design p ac ices de eloped
du ing and a e benchma king we e expe ienced as di icul pa s o
he p ocess. In he ollowing pa ag aphs, I will discuss he h ee needs
iden i ied om sub-s udy I.
Fi s , he e is a need o a equi ed se o design ools o pu ideas
in o p ac ice. He e, he heal hca e managemen had a need o isual ways
o dissemina e and communica e in o ma ion om he benchma king
si e isi s o he local heal hca e p o essionals, expe s, and communi ies.
Visualiza ion and conc e iza ion ools (Koh e al., 2011; Shneide man
e al., 2013) a e highly impo an du ing he benchma king p ocess bu
should be used mo e b oadly. In sub-s udy I, we ound ha isualiza ion
ools helped o c ea e a sha ed unde s anding o heal hca e ecosys ems,
which can suppo he implemen a ion o lean s a egies in heal hca e
p ocesses. In addi ion, h ough isualiza ions, we can aim o c ea e be e
communica ion and pa icipa ion.
Second, when issuing manda es, he e is a need o engage and
commi people om he hospi al, as no ed by We e -Edman e al.
(2018), who s essed ha s akeholde s’ pa icipa ion is c ucial and ha
we can impac and change hei beha io . In sub-s udy I, benchma king
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
96 97
encou aged heal hca e s a om he Lapland Hospi al Dis ic o discuss
no only se ice design app oaches in heal hca e bu also lean p ac ices in
he heal hca e con ex . The p ac ical examples helped hospi al managemen
and se ice design p ac i ione s unde s and how a se ice design app oach
would be an e ec i e pa o heal hca e- ela ed de elopmen in hospi als.
Thi d, he e is a need o scaling up he se ice expe imen s in
hospi als. He e, he se ice design p ac ices and ools a e ideal o zoom in
and ou o see he smalle de ails and he la ge o e iew (Polaine, 2013).
Du ing some o he benchma king si e isi s done du ing he i s case
s udy in sub-s udy I, hospi als an hei expe imen s i s in one uni and
la e scaled hem up o he o he uni s. We a gued in sub-s udy I ha
he scaling-up s ep is one o he challenges in se ice design and human-
cen e ed de elopmen . Scaling up se ices is pa o he change p ocess,
which equi es pee - o-pee lea ning. He e, ans o ma ional change in
he o ganiza ional cul u e and managemen ’s s ong commi men o
benchma king a e needed o ensu e ha he esul s o he se ice design
p ocess a e disce nable. The scaling-up s ep can ake inno a ions om
expe imen a ion o implemen a ion and s a egic day- o-day managemen .
The ole o se ice design could o e solu ions o mee ing all
he a o emen ioned needs. Se ice design ools can help o c ea e and
de elop mo e e ec i e benchma king p ocesses and gene a e suppo
and commi men o se ice ideas, which a ec s he o e all success o
de elopmen p ojec s. In sub-s udy I, we sugges ed ha se ice design
could use ideo pe sonas and sho commen a ies and s a emen s o
heal hca e p o essionals and pa ien s om he benchma ked hospi al and
also de elop ools o bo h designing and e alua ing agile expe imen s
based on benchma king. The documen ed da a om benchma ked
hospi als can also p o ide e idence o he se ice de elopmen p ocess
and suppo he se ice designe in hei ole. This use ul documen a ion
could also b ing se ice designe s’ ole close o he ea ly phase o he
design p ocess, when he designe can cap u e he con en s and ideas
gene a ed du ing he benchma king. The ideo eco dings om he ield
and isual ools can also be aluable o in e nal pu poses when aiming
o imp o e he in e nal cul u e, ini ia ing clinically meaning ul changes
in quali y, and b inging abou a “change in men ali y” in an o ganiza ion
h ough benchma king (Gleason & Bohn, 2017, p. 151).
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
98
4.1.2. Design Me hods as a Way o C ea e and Sha e a Vision and
Unde s and Ecosys ems
In sub-s udy I, we ound ha e en hough heal hca e p o essionals
in di e en municipali ies we e ac i ely wo king oge he , hey we e
s ill missing knowledge o he se ice p ocesses in di e en hospi als.
This challenge migh make he se ices slowe o e en unob ainable,
especially when a p o ince consis s o many municipali ies ha should
seamlessly coope a e. Sub-s udy I demons a ed ha isualiza ion and
conc e iza ion ools (Koh e al., 2011; Shneide man e al., 2013) enabled
be e communica ion and pa icipa ion in de elopmen p ocesses
and helped o c ea e a sha ed unde s anding o heal hca e ecosys ems,
which can suppo he implemen a ion o such hings as lean s a egies
in heal hca e p ocesses. In addi ion, as Hakio and Ma elmäki (2011)
a gued, pa icipa o y and isual design me hods i well in o enhancing
he c oss- unc ional collabo a ion in a public o ganiza ion. In he
ollowing pa ag aphs, I will s ess he alue o isualiza ion and se ice
design wo kshops especially om he e y ea ly phase o he de elopmen
p ocess.
Eigh municipali ies we e in ol ed in he de elopmen p ocess in
case s udy 2 o sub-s udy I, whe e we de e mined ha one o he bigges
challenges is egional ba ie s. In o ma ion is missing om municipali y
o municipali y, which makes he se ices slowe o e en una ainable. We
isualized he esou ces as a bluep in empla e, which helped pa icipan s
in he ehabili a ion p og am sha e he in o ma ion among he
p o essionals, and h ough ha , o pe cei e he heal hca e- ela ed se ice
ecosys ems o municipali ies. In he se ice ecosys em le els de ised by
Bei ao e al. (2017), he esou ce bluep in is linked o he mic o and meso
le els in his esea ch. A he mic o le el, p o essionals inside he hospi al
sha ed knowledge and in o ma ion, and a he meso le el, p o essionals
in o he hospi als c ea ed an in e ac ion and communica ed oge he . The
bluep in is a use ul ool o managing complexi y (Polaine e al., 2013),
and he e o e, he bluep in isualiza ion as a conc e izing ool amasses
di e en da a, knowledge, se ice p ocesses, and he dis ic ’s ecosys ems
o e e yone o iew. He e, he esou ce bluep in was done a he beginning
o he de elopmen p ojec , and i was labo ious bu de ini ely equi ed a
he s a ing poin . The in o ma ion and knowledge we e inally eachable
and unde s andable, which helped no only du ing he de elopmen bu
also la e o unde s and wha se ice design ools and me hods he se ice
designe can b ing o he de elopmen . As Ve e li and Sche e (2019)
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
98 99
s essed, pa ien -cen e ed inno a ions a e di icul o each o because
he esou ces a e limi ed and he e is no consis en unde s anding o he
cu en si ua ion in o ganiza ions. The esou ce bluep in suppo s he
s uc u ing o hese si ua ions.
The ole o se ice design wo kshops was seen as a way o b ing
p o essionals “ inally” oge he and, h ough design me hods, o discuss
and de elop he heal h- ela ed p ocesses. As desc ibed in he second
case s udy o sub-s udy I, he heal hca e p o essionals saw he g ea alue
o ha ing su icien ime o ge o know each o he and discuss among
hemsel es. Al hough hey migh know each o he by name and migh also
ac i ely wo k oge he , o example, ia phone o email, hey may ne e
ha e me ace- o- ace. The p o essionals om he ehabili a ion ield we e
cu ious o know mo e abou he se ices, p ocesses, and he en i e dis ic ’s
ecosys ems as well as he esou ces and how hese we e dis ibu ed in he
municipali ies. In sub-s udy I, we disco e ed ha wo kshops a e no only a
g ea pla o m o mee ing people, bu hey also gene a e alue o u he
de elopmen p ojec s and inc ease mo i a ion o se ice inno a ions.
Wo kshops as a co-design pla o m a e also c ucial when de eloping
heal hca e p ocesses ac oss municipali ies, when i is c ucial o os e us ,
clea communica ion, and amilia i y wi h o he p o essionals. He e, he
ole o he se ice designe is pa icula ly impo an o achie ing equal,
high-quali y, and c ea i e coope a ion.
4.2. Pa ien s’ Expe iences o Heal hca e Se ices
Sub-s udy II answe ed he ollowing esea ch ques ion: How a e pa ien s’
expe iences conside ed when designing new hospi als and heal hca e
se ices? P e ious s udies ound ha he e a e po en ial bene i s o u ilizing
pa ien -cen e ed co-design in he heal hca e en i onmen (e.g., Done o e
al., 2015). This po en ial was also clea ly ecognized in bo h hospi als in
sub-s udy II, bu he esul s e ealed he exis ence o a ious challenges
and di e en opinions conce ning pa ien in ol emen and co-design
me hods, especially in he ea ly phase o he new hospi al cons uc ion
p ocess. In addi ion, due o schedule limi a ions, pa ien -cen e ed co-
design sessions we e di icul o u ilize, and he co-design me hods we e
no op imal o e e y issue o phase. I will now discuss hese issues mo e
ho oughly in he ollowing pa ag aphs.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
100
Limi ed Timescales and Resou ces
E en hough he da a in sub-s udy II we e limi ed and collec ed om wo
hospi als (H1 and H2), hey clea ly indica ed ha he e a e no common
p ac ices in pa ien in ol emen when designing new hospi als. One
o he no able esul s om sub-s udy II conce ned limi ed imescales
and esou ces in he use o co-design and pa ien -cen e ed me hods.
Limi a ions o ime and esou ces we e men ioned as ha ing he bigges
impac in a con ex o b inging co-design in o he long- e m p ocess o
new hospi al design, which is execu ed unde ime-schedule p essu e
and unde he guidance o a chi ec s. I was no ed ha he schedule o
he planning phase is usually so igh a he beginning ha he e is no
enough ime o go h ough all he p ocesses in he hospi al. In addi ion,
in a silo-s uc u ed o ganiza ion, he heal hca e p o essionals a e o en
op imized in hei own a ea o expe ise and, hus, he e a e challenges
in wa ds being able o “discuss” among each o he . This causes p oblems
when he ocus should be on he o e all ca ing p ocess, whe e he pa ien
is he main s akeholde who has o expe ience he en i e p ocess om one
silo o ano he . The impac o co-design me hods and hei challenges ha e
been in es iga ed in p io wo ks (e.g., Bowen e al., 2013; Canham e al.,
2016; Pi inen, 2016). As iden i ied by Canham e al. (2016) pa icipan s
o e -es ima ing he po en ial scope and ime scale o change is a main
challenge wi h co-design me hods in he heal hca e con ex . In addi ion
o hese issues, which we e also ecognized in sub-s udy II, one o he
men ioned s uggles was designing some hing o ally new in a hospi al.
Conc e izing he En i onmen
Ano he key inding o sub-s udy II conce ned conc e izing me hods
o mo e speci ically, conc e izing he en i onmen . He e, H2 used VR
wo kshops o conc e ize he se ice ideas in he new hospi al. They
s uc u ed he VR sessions so ha he hospi al s a i s es ed and
e alua ed he essen ial appa a us and equipmen , and subsequen ly, in he
second VR session, hey in i ed pa ien s o gi e hei opinions. They also
in i ed people om he cus ome ju y wi hou any speci ic expe ience o
he edesigned oom and people wi h eal-li e expe ience. Thus, hey could
ga he di e en obse a ions and commen s ha we e uly ele an . This
sub-s udy showed ha VR, as a way o conc e ize se ice p ocesses and
physical ouchpoin s, suppo ed he de elopmen o physical solu ions.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
100 101
A VR co-design session can add ealism o simula ed en i onmen s and
is an inexpensi e way o es , idea e, and de elop se ice scena ios and
physical mock-ups, such as isola ion ooms o sel - egis a ion machines.
In addi ion, VR simula ions and physical mock-ups as co-design p ac ices
can no only isualize he loo plans and equipmen layou issues bu also
elici he people’s oices.
As a low- ech e sion o VR echnology, H1 used a physical eplica
ha was buil in he pa king lo o he hospi al. The heal hca e s a could
isi , conc e ize, and es di e en appa a uses and equipmen in his
con ex , and eedback was collec ed and u ilized o u he use. No pa ien s
o cus ome ju y we e allowed in he loca ion o he physical eplica. The
app oaches o VR echnology and physical eplicas a e linked o p o o yping
p ac ices, which a e popula me hods in se ice design. When heal hca e
p o essionals can es ou some new ideas h ough physical eplicas, he
ideas de elop in hei minds a e wa ds, and hey make many sugges ions
la e . This causes di icul ies du ing he cons uc ion p ocess, because
any changes also a ec echnical issues. Knapp e al. (2016) also w o e
abou his phenomenon in design sp in s, speci ically ega ding when you
should be e u ilize he ime wo king alone, o example, in he e ening,
when he mind is s ill engaged in hinking abou wha has occu ed. A
he same ime, his should be conside ed in he schedule, whe e you i s
es he physical eplica and hen in oduce you sugges ions and ideas
he day a e . These p o o yping p ac ices a e no a new a ea in heal hca e
de elopmen .
The e a e good examples p esen ed om he ca dboa d hospi al by
K onq is e al. (2013) and how he eal-sized p o o yping en i onmen
could be pa o he building design p ocess wi h o he e alua ion
me hods, such as i ual simula ions and es p o o ypes cons uc ed
o wood panels. As ano he example, K onq is e al. (2013) sugges ed
gami ica ion me hods o b ing pa ien -cen e ed and holis ic unde s anding
in o heal hca e de elopmen . He e, pa ien expe iences we e discussed
h ough he cus ome jou ney as a game boa d, which assis ed he pa ien s
in he in e iews in emembe ing, unde s anding, and discussing hei
expe iences. The game boa d me hod could also be u ilized o de elop
he new hospi al cons uc ion p ocess, whe e pa ien s’ li ed expe iences
should be conside ed. The game boa d o , simila ly, a desk op walk h ough
helps o pe cei e, o example, dis ances when he eal-size p o o yping o
VR helps in es ing ou he de ails in a speci ic momen , such as a isi o
a ea men oom. To link hese me hods, we ollowed a con inual p ocess
o se ice design p ac ices, whe e we zoomed in and ou o see he de ails
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and o e iews (Polaine, 2013).
Benchma king he Co-design Me hods
Sub-s udy II examined he use o benchma king o adop he bes
p ac ices o pa ien -cen e ed ca e in he ea ly phases o new hospi al
design, which was ac ually done in H2. They used ime o obse e how
o he hospi als u ilized di e en co-me hods and good p ac ices o u he
hei own cons uc ion p ojec s and duplica ed hem in hei p ac ice. As
a compa ison, H1 acknowledged in hindsigh ha i would ha e been
bene icial o ha e mo e esou ces, ime, and co-design me hods o he
planning phase. Mo eo e , du ing he ea ly de elopmen phases, bo h
hospi als u ilized he cus ome ju y, which consis ed o ci izens whose ole
was o ep esen he pa ien s. The alue o ha ing pa ien s as pa o he
co-design p ocess was seen di e en ly. H2 saw a lo o alue in in ol ing
eal use s in he p ocess and, he e o e, nomina ed a pe son o in es iga e
se ice lows, especially o ensu e ha he hospi al’s ope a ion was e ec i e
and pa ien -cen e ed. They also o ganized wo kshops wi h pa ien s, seeing
hei in ol emen as c ucial du ing he design phase. Con e sely, H1 did
no see much alue in his in he ea ly phases, s a ing ha he e migh be
oo many di e en opinions.
In addi ion, sub-s udy II ound ha he da a om cus ome ju y
mee ings o wo kshops was no always u he p ocessed and u ilized.
He e, as an example, H1 o ganized a wo kshop wi h he cus ome ju y, bu
he da a we e ha dly used, i a all. I was also obse ed in sub-s udy II ha
in he wo kshops ha did no include pa ien s, he heal hca e p o essionals
some imes sha ed hei own knowledge based on he eedback hey had
pe sonally ecei ed om pa ien s. This eedback conside ed issues in
he ea men p ocess o de ails o he hospi al building. The wo kshops
we e momen s o emembe and oppo uni ies o sha e eedback. This
obse a ion indica es ha pa ien expe iences a e impo an o heal hca e
p o essionals e en i he pa ien s hemsel es a e no p esen o sha e hem.
4.3. S eng hs and Weaknesses o Heal h-Rela ed Design
Sp in s
Sub-s udy III examined he ollowing esea ch ques ion: Wha a e he
s eng hs and weaknesses o heal h- ela ed design sp in s? The sub-
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102 103
s udy was conduc ed h ough h ee design sp in s un in h ee hospi als
in Sweden, Es onia, and Finland, espec i ely. Findings om he collec ed
da a ( esea ch dia ies, ield no es, and in e iews) highligh ed six s eng hs
and h ee weaknesses om he pa icipan s’ poin s o iew (Table 5).
Using hese as hemes, we ca ego ized hem in o wo main esul a eas:
(1) challenges o change in design sp in s and (2) syne gy in agile ways o
doing. In he ollowing pa ag aphs, I will discuss hese wo a eas in mo e
dep h.
Table 5. S eng hs and weaknesses om design sp in pa icipan s’ pe spec i es.
Challenges o Change in Design Sp in s
The ole o se ice design in heal hca e has become impo an . Howe e ,
he changing wo ld o new echnologies, aging popula ions, con inuous
g ow h, and social and heal hca e e o ms (e.g., Clack & Ellison, 2019;
F y, 2019) a e challenging heal hca e- ela ed se ice design. Ob iously, a
design sp in alone is no a solu ion o ackling hese challenges, bu i can
open new oppo uni ies in he heal hca e ield. Lea ning was highligh ed
as he g ea es s eng h in he heal h- ela ed design sp in s, which was
s ongly linked o design hinking and design me hods, and i was shown
ha i can suppo change in co-design p ocesses and se ices (Kuu e e al.,
S eng hs and weaknesses om pa icipan s’ poin s o iew
S eng hs Weaknesses
- Lea ning design hinking and
design me hods
- O ganiza ional change
- Dialogue be ween s akeholde s
associa ed wi h di e en design
me hods
- Unde s anding hospi al p ocesses
om he end use ’s pe spec i e
- Emphasizing s akeholde s by
employing co-designing
- O he ele an insigh s ega ding
hospi al se ices
- Unde s anding he bigge pic u e o
hospi al p ocesses and sys ems
- Rele ance o he c ea ed se ice
concep
- E hical limi a ions and
conside a ions
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2014). Pa icipan s (bo h heal hca e ep esen a i es and s uden s) lea ned
o use design me hods in di e en phases du ing he design sp in p ocess,
and his also inc eased hei capabili ies in design hinking. Lea ning
occu ed wi hin he design sp in eams when impo an knowledge could
be immedia ely sha ed. In addi ion, he heal hca e p o essionals we e
mo i a ed o implemen some o he design me hods in hei e e yday
p ac ices, which had an impac on he ans o ma ion when design ools
and skills we e pa o he o ganiza ional capaci y o ongoing change
(Bu ns e al., 2006; Sangio gi, 2011).
One o he challenges o change in heal hca e o ganiza ions is
ailing o lea n om ailu es (Edmondson, 2004; F y, 2019) and a oiding o
managing isks and/o cos s (Clack & Ellison, 2019; F y, 2019; Jones, 2013).
In his sub-s udy, one iewpoin was o ocus on he oles o ole-playing
and p o o yping when es ing di e en se ice concep s. Role-playing
enabled us o es ideas in a sa e en i onmen and i e a e hem u he —
his also included ailing and lea ning mo e abou isks. In addi ion, i was
easie o heal hca e ep esen a i es o sugges ea u es and unde s and
how echnology i s in heal hca e p ocesses. Se ice p o o yping can be
said o be “quick and di y,” which is an explo a i e and “goal-o ien ed bu
play ul way” (Schulz e al., 2015, p. 323). I is so “low- ech” ha sugges ions
o be e de elopmen ideas a e easie o exp ess. In addi ion, e y limi ed
ime ames in he design sp in p ocess kep he p o o ypes e y ough.
We used men o ing in ou design sp in s, whe e he heal hca e
p o essionals and expe s om di e en wa ds o he hospi al isi ed
design sp in eams o sha e hei knowledge, mo i a ion, and ideas.
Men o ing can be a c ucial pa o heal hca e- ela ed design sp in s when
he o ganiza ion is silo-s uc u ed and complex. Thus, we ca e ully selec ed
he men o s o hei open-mindedness and willingness o acili a e
changes in heal hca e. As hie a chical and silo-s uc u ed o ganiza ions
p e en g ow h (Done o e al., 2015; F y, 2019; Radno e al., 2012),
h ough design me hods, we enabled a pla o m o p o essionals o discuss
hei expe iences and pe cei e a holis ic pic u e o heal hca e se ices,
especially om he pa ien ’s poin o iew. The conc e e design me hods,
such as isualiza ions me hods, s o yboa ds, and desk op walk h oughs,
suppo ed he unde s anding o holis ic se ice jou neys and emphasized
he s akeholde s no only om he pa ien ’s pe spec i e bu also om ha
o he hospi al p o essionals’ daily wo k li e. Thus, i was impo an o ha e
a conc e e and eal pic u e o whe e he se ice would be deli e ed. Design
me hods also suppo ed he dialogue among pa icipan s, especially
du ing he men o isi s.
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Table 6. Key indings om sub-s udy I
Sub-s udy I highligh ed wo main a eas ha a e ele an o his esea ch
ques ion.
Benchma king as a ool o de elop hospi al managemen p ac ices:
Benchma king is aluable o e idencing di e en managemen p ac ices
based on lean, agile, human-cen e ed app oaches and quali y, e ec i eness,
and imely a ailabili y o se ices. Benchma king also con ibu es when
de eloping agile expe imen s and e alua ion p ac ices. I is a as and cos -
e ec i e app oach o unde s anding he bes p ac ices o pa ien -cen e ed
ca e, especially o he new hospi al p e-cons uc ion phase.
The design ield is lacking s uc u ed p ac ices and ools o do benchma king
in complex o ganiza ions. Thus, we iden i ied h ee c ucial needs:
- The need o engage and commi people om he hospi al o be pa o he
benchma king, o example, how heal hca e p o essionals could be mo e
ac i ely in ol ed in da a collec ion du ing benchma king o how hey could
be expe iencing benchma ked p ocesses.
- The need o adop ing heal hca e- ela ed benchma king p ac ices and
ools in se ice design, especially he implemen a ion o and commi men
o hese du ing and a e benchma king. He e, we discussed he oles o
isualiza ion, ideo pe sonas, and sho commen a ies and s a emen s om
he benchma ked hospi al.
- The need o lea n new ways o scale up se ice expe imen s in hospi al
en i onmen s, such as how he se ice inno a ions could be es ed o agile in
di e en wa ds and applied o hese di e en en i onmen s.
Design me hods as a way o c ea e and sha e a ision and unde s and
ecosys ems:
Heal hca e p o essionals a e missing knowledge o se ice p ocesses om
di e en hospi als, which migh make he se ices slowe o unob ainable.
Fu he mo e, isualiza ion and conc e iza ion ools no only suppo
communica ion and pa icipa ion bu also os e unde s anding o he
heal hca e ecosys ems h ough silos, municipali ies, and egional ba ie s.
The esou ce bluep in is a ool o pe cei e di e en ecosys ems and hei
laye s. In addi ion, i makes in o ma ion sha ing and se ice de elopmen
easie h ough egional ba ie s.
Se ice design wo kshops p o ide a g ea oppo uni y o inally b ing people
oge he o mee each o he . Wo kshops gene a e alue o u he de elopmen
p ojec s, inc ease mo i a ion o he se ice inno a ions, and p omo e us ,
clea communica ion, and amilia i y wi h o he p o essionals.

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112
Table 7 in oduces he key indings om sub-s udy II and answe s i s
esea ch ques ion: How a e pa ien s’ expe iences conside ed when
designing new hospi als and heal hca e se ices?
Table 7. Key indings om sub-s udy II.
The esul s om sub-s udy II indica ed he exis ence o a a ie y o challenges
and di e en opinions abou pa ien in ol emen and co-design me hods
especially in he ea ly phase o he new hospi al cons uc ion p ocess. He e, I
desc ibe he h ee main hemes we de e mined.
Limi ed imescales and esou ces in he use o co-design and pa ien -
cen e ed me hods we e s essed as one iden i ied challenge, which also had
an impac in he con ex o b inging co-design in o he long- e m p ocess o
a new hospi al. In cons uc ion p ojec s, he ime p essu e is igh , especially
a he beginning, and hus, he e migh no be enough ime o go h ough
all he p ocesses. In addi ion, heal hca e p o essionals a e op imized o hei
expe ise, which suppo s he silo s uc u e. O e es ima ing he po en ial
scope and imescale o changes was seen as c i ical in co-design me hods,
especially when designing some hing o ally new.
Conc e izing he en i onmen , especially in a new cons uc ion p ojec ,
was de ined as a challenge. VR co-design wo kshops we e u ilized and ound
o be a good me hod o ou line spaces by adding mo e ealism. I was an
inexpensi e way o es , idea e, and de elop se ice scena ios and physical
mock-ups. Ano he example was o build a physical eplica.
Benchma king was used in his sub-s udy o adop he bes p ac ices o
pa ien -cen e ed ca e and co-design me hods.
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112 113
Table 8 summa izes he key indings om sub-s udy III and answe s i s
esea ch ques ion: Wha a e he s eng hs and weaknesses o heal h-
ela ed design sp in s?
Table 8. Key esul s om sub-s udy III.
Challenges o change in design sp in s
- Lea ning was seen as a s eng h in design sp in s, which was linked o design
hinking and design me hods. Some o he design me hods lea ned du ing he
design sp in s we e implemen ed in he e e yday p ac ice o he hospi als by
heal hca e p o essionals.
- Role-playing enabled us o es se ice ideas in a sa e en i onmen and i e a e
hem u he . This had an impac on ailing and lea ning mo e abou isks.
- Heal hca e p o essionals and expe s, who we e ca e ully selec ed o hei
open-mindedness and willingness o acili a e changes in heal hca e, mainly
pa icipa ed as men o s in he design sp in s.
- The design sp in did no allow pa icipan s o ocus on he en i e heal hca e
p ocess in dep h, making issues ela ed o go e nance, s a egies, poli ical
will, and economics he mos di icul o conside . Thus, he design sp in s in
some cases had nega i e e ec s on concep idea ion, us , and he ele ance
o he inal ou come.
- Pa icipa ion was highligh ed as he mos impo an way o achie e change
inside a heal hca e o ganiza ion when heal hca e ep esen a i es, a ious
expe s, manage s, pa icipan s om di e en backg ounds, and designe s
de elop oge he .
Syne gy in agile ways o doing
- The acili a o ’s ole was c ucial o boos ing syne gy wi hin he design sp in
eams. Syne gy and dialogue among all people in ol ed we e mo e impo an
han he end esul i sel .
- Well- acili a ed p ocesses, ca e ully selec ed design me hods, and open-
minded men o s c ea e syne gy, which helps o o e come challenges
associa ed wi h making changes in he heal hca e sec o .
- Respec mus be c ea ed o e e yone’s knowledge, skills, and p o ession.
Design me hods wo ked as a pla o m o applying hese skills, and h ough
ha , us and mu ual lea ning we e gene a ed wi hin he eam.
- Design sp in s we e seen as an example o o sho in oduc ion o he design
ield, a kick-o o new hospi al p ojec s, o a boos e du ing he middle phase
o a p ojec , no aimed a achie ing conc e e ou comes o implemen a ion.
- The design sp in app oach amilia izes people inside an o ganiza ion
wi h wha can be aimed o and achie ed wi h design p ac ices and how he
di e en design me hods can sys ema ically build knowledge, de ine insigh s,
and c ea e solu ions.
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5. Discussion
114
Las ly, he key esul s om sub-s udy IV a e highligh ed in Table 9.
The sub-s udy’s esea ch ques ion was as ollows: How can heal hca e
ep esen a i es suppo design sp in s in he de elopmen o heal hca e-
ela ed se ices?
Table 9. Key indings om sub-s udy IV.
We iden i ied ou oles o pa icipa ing heal hca e ep esen a i es: eam
membe , lea ne and design hinke , men o , and acili a o . These iden i ied
oles we e he basis o he de elopmen o a ou - heme amewo k ha
could be used o co-design and human-cen e ed design sp in s. The hemes
a e b ie ly in oduced below.
Lea ning and knowledge sha ing
This in ol es no only gaining a be e unde s anding o me hods in he design
p ocess bu also lea ning o unde s and, apply, and use design me hods and
design hinking in u u e wo k.
Design hinking, suppo , and pa icipa ion
Designe s (o en also acili a o s) guide dialogue, suppo he usage o design
me hods, help o empa hize wi h people, and selec he bes possible ools o
unde s anding he da a, hei insigh s, and ou comes.
Powe sha ing and men o ship
Expe s can cla i y he complex and mul i-laye ed heal hca e p ocesses o
s uden s who can hen gain deep insigh s in o he heal hca e sys ems as a
esul .
Facili a ion
The ole o acili a o is c ucial du ing he design sp in p ocess, whe e di e en
skills a e needed o achie e he aims o planned ou comes. Facili a o s need
o unde s and how o app oach he design b ie , how o apply di e en design
me hods, how o collabo a e wi h pa icipan s om di e en ields, and how
o manage ensions and con lic s du ing co-design.
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5. Discussion
114 115
This doc o al disse a ion ocuses on answe ing he main esea ch ques ion:
How can se ice design and co-design app oaches suppo he ea ly
phase o heal hca e- ela ed se ice de elopmen ? I ha e add essed his
ques ion h ough he ou sub-ques ions o mula ed espec i ely in he
ou sub-s udies which ha e p o ided he basis o my esea ch. The sub-
s udies, which answe ed hese sub-ques ions, we e in oduced in dep h in
he p e ious sec ions, each ending wi h a sho summa y. In his sec ion,
I will i s e lec on he main esea ch ques ion in e ms o my heo e ical
backg ound and hen p opose a p ac ical amewo k o he ea ly phase
o heal hca e- ela ed se ice de elopmen , discussing i h ough he
lenses o objec i es, impac and alues, and design me hods and ools. In
addi ion, I will highligh he se ice ecosys em le els and how he p ac ical
amewo k helps o ou line hese di e en se ice ecosys em le els. This
unde s anding can be u ilized especially when planning a design p ocess
o heal hca e- ela ed se ice de elopmen .
5.1. P elimina y P epa a ion and E idence
P e ious s udies ha e discussed whe e se ice design should ha e i s
place and impac in he de elopmen p ocess (e.g., Almq is , 2017, 2020;
Cla wo hy, 2013; Raun, 2017; Yu & Sangio gi, 2014). In ac , some o he
ecen li e a u e has no ed ha he ea ly phase o he design p ocess, he
so-called uzzy on end, has al eady been in es iga ed, and i is, he e o e,
ime o ocus on he la e phases whe e implemen a ion occu s. I has also
been c i ically s a ed ha di e en design-led p ocesses and oolboxes ha e
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
116
been he only ou comes o o ganiza ional de elopmen and design has no
eached he desi ed capaci y (Holmlid & Malmbe g, 2018; Malmbe g,
2017). Howe e , he on end is he mos in o ma ion-in ensi e phase,
whe e di e en ypes o in o ma ion om in e nal and ex e nal sou ces
a e b ough in o he p ojec (Zahay e al., 2004) and he majo decisions
a e made (Cla wo hy, 2013); hus, we should pu mo e e o in o he ea ly
phase. I is also a momen whe e he eam membe s ge o know each o he
and he gi en b ie and he eam plans he de ails o he p ojec .
In his esea ch, p elimina y p epa a ion was p o ided h ough
benchma king and p epa ing he benchma king da a and design sp in s.
The sub-s udies in oduced in his esea ch ound ha he e a e elemen s
ha se ice designe s should conside be o e s a ing a heal hca e- ela ed
se ice de elopmen p ojec . These elemen s a e ela ed o building us
and engagemen among pa icipan s; unde s anding he se ice design
and co-design; lea ning design p ac ices, p ocesses, and me hods; and
adap ing he p ocess o he e e yday wo k p ac ices. F om he se ice
design and co-design poin s o iew, he p elimina y p epa a ions aim
o e idence he po en ial o se ice design and he alue o co-design
h ough he en i e de elopmen p ojec and o a oid lea ing he designe s
ou side o he p ojec wi h he impo an and deepes insigh s o he use s
in hei hands, as Almq is (2017, 2020) has explained. The di e en oles
and pa icipa ion o se ice designe s and o he s akeholde s can hen be
jus i ied mo e clea ly h oughou he p ojec .
In addi ion, he p elimina y p epa a ions aim o a oid uzziness a
he beginning o he se ice de elopmen p ojec . When he g oundwo k
is planned, e idenced, and p epa ed well, we can es ablish a be e
unde s anding o he objec o be de eloped on he basis o he ini ial
knowledge and consequen ly p o ide mo e e idence o he o ganiza ional
and design le els be o e he ac ual de elopmen p ojec begins. Acco ding
o Foglieni e al. (2017), e idence is needed o decision-making a bo h
he o ganiza ional le el and he design le el, which helps o d i e lea ning,
change, and ans o ma ion s ep-by-s ep. A he o ganiza ional le el, he
e idence can be u ilized while planning he s uc u e o he design p ocess
o se ice de elopmen and c ea ing a common unde s anding om
i . The ollowing ques ions can hen be conside ed: Wha is he aim o
de elopmen in complex o ganiza ions; wha is included and excluded in
he b ie ; how can we de ine he se ice unde de elopmen ; and wha
a e he esou ces o each wa d/hospi al om he se ice de elopmen and
p ocess engagemen poin s o iew?
In his esea ch, e idence was ga he ed h ough se ice design

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me hods, whe e he da a collec ed om he ield, o example, h ough
benchma king o ques ionnai es, we e isualized by using di e en
mapping ools. These mapping ools can be, o ins ance, se ice jou ney
mapping o esou ce bluep in s, which we e also u ilized and analyzed
in sub-s udies I, III, and IV o his esea ch, and hey can be bene icial
o de elopmen especially in he beginning o he p ocess. In addi ion,
h ough o he conc e e design me hods, such as p o o yping and desk op
walk h oughs, e idence can be c ea ed when conc e ely desc ibing he
expe iences o s akeholde s o s epping in o he shoes o ano he . In his
esea ch, I saw he e idence as being conc e ized and obse ed s a egic
benchma king p ocess and isualiza ion ools helping o pe cei e he
complexi ies in he silo-s uc u ed o ganiza ions.
The alue o using benchma king is ha i builds e idence ha
is ga he ed om o he (heal hca e) o ganiza ions. The e idence om he
benchma king can be, o example, how o he o ganiza ions a e p oducing
a se ice, how he change has been implemen ed in an o ganiza ion, o
how hey ha e success ully u ilized and used design me hods as pa
o se ice de elopmen . Benchma king is al eady well known in he
heal hca e indus y, whe e i has been used o e he yea s o quali y in
heal hca e se ices (Kay, 2007), and hus, he leap in o new app oaches is
no signi ican ly di e en .
The po en ial o u he de elop he benchma king p ocesses,
isualiza ion ools, and p o o yping me hods o bo h designing and
e alua ing agile expe imen s based on benchma king exis s. As p o o yping
sa es esou ces, such as ime and money (Blomk is , 2014), i could be a
bene icial ool in benchma king, o ins ance, du ing new cons uc ion
p ojec s o in agile expe imen s du ing he design sp in s in he ea ly phase.
Howe e , combining his benchma king in o isualiza ion and p o o yping
equi es p epa a ions o which he se ice designe has expe ise. As
emphasized in sub-s udy I o his esea ch, heal hca e managemen has
exp essed a clea need o ind isual ways o dissemina e and communica e
benchma king in o ma ion o la ge audiences in hei home communi ies.
The e o e, he design sp in wi h p epa ed benchma king e idence could
be one success ul way o dissemina e and communica e in o ma ion.
Se ice design could, o ins ance, ocus on using ideo pe sonas and
sho commen a ies and s a emen s om indi iduals me du ing he si e
isi s o on gene a ing he digi al benchma ked da a o VR. The usage o
VR in heal hca e se ice de elopmen was ound o be a good p ac ice in
sub-s udy II.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
118
5.2. Familia iza ion wi h he Unknown
Challenges o change a ise when heal hca e o ganiza ions aim o
inno a ion and de elopmen (e.g., F y, 2019). E en hough heal hca e
and design ha e had a long his o y oge he in heal hca e se ice
imp o emen (Rowe e al., 2020), s udies ha e shown ha he ield is s ill
lacking knowledge o , o ins ance, selec ions o pa icipan s o co-design
wo kshops (Boyd e al., 2012) and communica ion abou design in e ms
o heal hca e e minology, us , and sha ed unde s anding (Hakio &
Ma elmäki, 2011). In addi ion, issues such as he isk o losing c edibili y
o ea o design p ac ices may exis (Hakio & Ma elmäki, 2011). As no ed
in he li e a u e, se ice design is s udied o be a ca alys o o ganiza ional
change and ans o ma ion (Junginge , 2015; Yu & Sangio gi, 2018), and
i would be aluable o in ol e and engage heal hca e p o essionals who
a e in e es ed in and cu ious abou design. The e is a need o ha e hese
p o essionals om he heal hca e ield as pa o he se ice design p ocess
o impac and change he beha io o s akeholde s (We e -Edman e al.,
2018).
Se ice design, as a de elopmen app oach, migh be a s ange
way o wo king o se e al p ac i ione s in he ield o heal hca e and i ,
hus, aises many ques ions and unce ain ies. Ne e heless, he cu iosi y
and suspicion abou se ice design did no go unno iced du ing he sub-
s udies o he esea ch. The e is a ue need o p o ide new ini ia i es o
he ea ly phase o he se ice de elopmen p ocess in complex heal hca e
o ganiza ions and aim o be e and mo e e icien coope a ion. The goal
he e is o amilia ize people om he heal hca e ield wi h se ice design
and co-design so hey can be e con ibu e o he p ojec planning and
sugges how he me hods can be be e adap ed o hei e e yday p ac ices
du ing he design p ocess o se ice de elopmen . This is impo an when
wo king wi h people who a e busy and o en o e bu dened wi h hei
wo k.
This esea ch indica es ha an in ensi e design sp in is a way o
suppo heal hca e- ela ed se ice de elopmen h ough se ice design
and co-design app oaches. I is seen he e as an example o in oduce
he design p ocess, design me hods and ools, and wha can be achie ed
h ough hem. The o e iew o he design p ocess in oduced h ough a
design sp in gi es alue o se e al issues. As highligh ed in sub-s udies
III and IV, a key elemen o unde s anding, applying, and using design
me hods and design hinking was lea ning o use design me hods.
An agile way o hands-on doing c ea ed a syne gy among pa icipan s,
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
118 119
p o essionals, and expe s om di e en silos who we e in ol ed and
engaged in sha ing hei knowledge and insigh s. They lea ned o use
di e en design me hods and hey unde s ood he alue o isualiza ion,
especially om he iewpoin o complexi y. Mos impo an ly, he design
sp in was no only aluable o he upcoming p ojec planning bu , as
he indings o sub-s udy IV s essed, he design me hods used du ing he
design sp in we e ans e ed o e e yday wo k and we e no used only
o he pu pose o achie ing he goals o he design sp in . This migh
also ha e an impac on he eme gence o comple ely new ypes o design
me hods in he heal hca e ield when hey a e co-designed by designe s
and heal hca e p o essionals.
Design sp in s would add e en mo e alue o he se ice de elopmen
p ocess i managemen we e be e in ol ed. Change o ans o ma ion
in an o ganiza ion happens h ough lea ning (Kuu e e al., 2014), and
one o he mos powe ul ways o achie e change is o o ganiza ions o
communi ies o s a s ee ing changes hemsel es (Sangio gi, 2011). F om
his poin o iew, he ole o managemen is pa icula ly impo an , and
hus, i should no be unde es ima ed o comple ely igno ed. I is un o una e
ha some imes p ojec s ha a e ca ied ou in coope a ion wi h academic,
design-d i en case s udies ge app o al om managemen , bu he e is no
u he in e es om managemen he ea e in pa icipa ion. Al hough
heal hca e p o essionals may be en husias ic abou se ice design and
c ea i e co-design me hods, hei implemen a ion and, hus, he cul u e o
change a e no aking o . Fo his eason, s a managemen is necessa y
when changes mus be adop ed and implemen ed in he heal hca e s a ’s
wo k li e (e.g., Nilsen e al., 2016; S ickdo n & Schneide , 2011), and one
way o be e engage hem is o amilia ize hem wi h he unknown.
He e, an agile and in ensi e design sp in (e.g., Knapp e al., 2016)
o e s a quick o e iew o he design me hods and design p ocess, bu
abo e all, h ough a igid and acili a ed p ocess and elemen s o agile,
design, and lean hinking, he design sp in eams lea n o p oduce a
minimum o iable se ices (Magis e i e al., 2019) and implemen he
design p ac ices o u u e se ice de elopmen p ojec s. In addi ion,
agile expe imen s ha e alue when ailu es occu in a sa e en i onmen ,
be o e ac ual implemen a ion. Failing is seen as a isk in heal hca e, as
ailu e migh lead o a pa ien ’s dea h (e.g., Edmondson, 2004). Fo ha
eason, design sp in s a e good oppo uni ies o ad ance cul u al shi s in
o ganiza ions whe e ailu e can be handled sa ely (Ku onen, 2017), and
hus, design sp in s can be a majo s a ing poin in he de elopmen o
heal hca e se ices and in a design-cen ic cul u al change.
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
120
As explained in sub-s udies III and IV, design sp in s should a he
be seen as an example o o sho in oduc ion o he design ield o a kick-
o o new hospi al p ojec s, no aimed a achie ing conc e e ou comes
o implemen a ion bu , a he , a unde s anding wha can be aimed a
and achie ed wi h he design app oaches, and sys ema ically building
knowledge, de ining insigh s, e ining esea ch ques ions, and c ea ing
p elimina y solu ions. In addi ion, in pe cei ing mo e ealis ically which
se ice ecosys em le els he de elopmen p ojec eaches, we can plan
be e how many esou ces we need, how la ge a collabo a i e ne wo k we
should c ea e o he p ojec , whom we wan o in ol e in he p ojec , and,
o example, how much ime is needed o he p ojec .
5.3. P ac ical F amewo k o Heal hca e Se ice
De elopmen
Se ice design has he po en ial o suppo heal hca e- ela ed se ice
de elopmen especially o complex, silo-s uc u ed, mul i-s akeholde
se ices, whe e p ocesses, esou ces, managemen s uc u es, and isions
should be be e unde s ood. As a esul , i is impo an o ealize, o
ins ance, he esou ces, ime, and design me hods equi ed o he se ice
o be de eloped. The e a e no igh solu ions o app oaches o acili a ing
he design p ocess o heal hca e- ela ed se ice de elopmen , bu he e
a e issues o conside ha suppo he s a ing poin and, hus, help in
u he phases when he ac ual design p ocess o se ice de elopmen
s a s. The ollowing Figu e 20 illus a es he loca ion o he p ac ical
amewo k in his esea ch and i s h ee s eps. The p ac ical amewo k is
called P e-phase o heal hca e se ice de elopmen .
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
126 127
This will equi e, among o he hings, he decision ega ding he se ice o
be de eloped o be made be ween he pa ne s—in his example, Es onia,
Sweden, and Finland.
The aim o he Co-designing heal hca e p ojec was o educa e
mo e designe s o gain se ice design expe ience in he heal hca e sec o ,
and also o educa e heal hca e p o ide o use “design as p ocess” and
“design as s a egy”. This c oss-bo de collabo a ion wi h he heal hca e
sec o , he design indus y, academia, and o he ele an collabo a o s can
be a key o mac o-le el changes as mo e e idence eme ges o he po en ial
o se ice design and co-design app oaches.
These h ee design sp in s also s eng hened he heal hca e- ela ed
design ne wo k h ough in e na ional, academic collabo a ion ha has
emained s ong since he p ojec s. Wi h hese p ojec s, se ice design and
co-design can be lea ned in complex heal hca e en i onmen s no ma e
how simple o demanding he objec o be de eloped is. In addi ion, he
design will be b ough close o he heal hca e ield and he p o essionals
wo king he e. I also belie e ha small mic o le el changes ha e long- e m
posi i e e ec s on bo h meso and mac o le el changes, and as discussed in
sub-s udy I,
Se ice design and i s mul iple me hods a e a good op ion when
designing new heal hca e se ices, especially when hese combine
a ious heal hca e ecosys ems. Se ice design ools c ea e en y
poin s and pla o ms o de eloping sha ed unde s andings and
insigh s and nego ia ing e o ms o heal hca e p ac ices and pa ien -
cen ed p ocesses. (Mie inen & Alhonsuo, 2019, p. 494)

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
Pic u e: Maileena Tuokko
128
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
6. Conclusions
128 129
6.1. Impac s o he Resea ch
The no el y o his esea ch is i s in oduc ion o a p ac ical amewo k o
he ea ly s age o he de elopmen p ocess. The impac o he amewo k
elies on se e al issues. Fi s , i can os e he ole o se ice designe om
he beginning o he de elopmen p ocess and—ins ead o wha Mulgan
(2014) s essed as designe s ha ing a “lack o a en ion o o ganiza ional
issues and cul u es” (p. 4)—aim o inc ease he knowledge and a en ion
o o ganiza ional issues and cul u es. This knowledge in designe s’ hands
could help se ice designe s o be e plan he en i e design p ocess, no
only ouching on he ope a ional le els bu also in ol ing he s a egic
le els a he ea lies possible s age.
I belie e he e a e design ools ha clea ly ha e a s onge impac
on he s a egy o an o ganiza ion and should play a mo e impo an ole
in he complex se ice design. Benchma king, which was also in oduced
in his esea ch in sub-s udy I, emphasizes one o hese me hods and
should be u he in es iga ed. I also belie e ha by engaging heal hca e
p o essionals in he ea ly phase o se ice de elopmen , mo e speci ically
in he p e-phase o heal hca e se ice de elopmen , hey ha e a mo e
impo an ole in in luencing no only he planning and scheduling o he
de elopmen p ocess bu also he applica ion o he design me hods used
in busy heal hca e wo k.
Medical and nu sing educa ion u ilizes simula ions, which is
no a new eaching me hod in heal hca e (Poikela, 2017). Fu he mo e,
hospi als a e using scena io-based simula ion aining in hei e e yday
p ac ices. These simula ions ha e simila i ies o se ice p o o yping, and
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
130
so he e is place o adap he wo o each o he . In addi ion, lec u e and
eaching inpu on se ice design has been inc easingly sough in nu sing
educa ion, a leas a he Lapland Uni e si y o Applied Sciences. Thus,
se ice design could ha e an impac on nu sing educa ion by adap ing
i s app oaches o he lea ning p og ams. In addi ion, collabo a ing
heal hca e- ela ed se ice de elopmen wi h nu sing and design educa ion
and p o essionals om he heal hca e ield migh ha e an impac on he
u u e whe e inno a ion is no longe seen as dis up i e om he poin
o iew o being a isk o clinical se ice, as Jones (2013) and Clack and
Ellison (2019) ha e explained. The ways o collabo a ing h ough se ice
design and co-design can b ing p o essionals om di e en silos oge he
and, hus, a oid hie a chy being an obs acle o g ow h (e.g., Done o e al.,
2015; Radno e al., 2012). Imp o ing and inc easing he unde s anding
o design-cen e ed app oaches a he educa ional le el migh also ha e
an impac on he s a egic le el o he heal hca e sec o : he mo e you
ecognize hese c ea i e app oaches, he easie i is o he designe o ge
in ol ed in he se ice de elopmen p ocess.
6.2. Sugges ions o Fu he Resea ch
Heal hca e is a complex and mul i-laye ed ield ha o e s many design-
ela ed oppo uni ies and in e plays be ween di e en se ice le els. I s
siloed s uc u e enables a g ea pla o m o se ice design o ackle many
di e en cases. When summa izing he sub-s udies o his esea ch, he
oppo uni ies o u u e in es iga ions became ob ious. He e, I would like
o again emphasize he ole o benchma king h ough he se ice design
app oach as a way o de elop heal hca e- ela ed se ices. A well-known
se ice design me hod is p o o yping (e.g., Blomk is , 2012; Coughlan,
Ful on Su i, & Canales, 2007; Holmlid & E enson, 2007), whe e se ice
scena ios a e simula ed h ough ole-playing o conc e ized h ough
pape -based o Lego Se ious Play desk op walk h oughs. These help
people play h ough he se ice expe iences be o e es ablishing hem in
an o ganiza ion (Holmlid & E enson, 2007), which can be a way o b ing
mo e e idence in o he de elopmen p ocess. Acco ding o F y (2019),
new ini ia i es need mo e e idence. The e is g ea po en ial o in es iga e
how well we can b ing e idence in o de elopmen when we benchma k
heal hca e se ices h ough p o o yping. In he se ice design ield, se ice
p o o yping has shown good ou comes in lea ning (Kuu e & Mie inen,
2013) and ans o ma ional change in he case o social se ices (Kuu e e
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
130 131
al., 2014), which, compa ed wi h heal hca e se ices, also has some complex
and silo-s uc u ed elemen s. Acco ding o Blomk is (2012), p o o yping
can be conduc ed a ou le els: (1) a i ac , (2) use, (3) con ex , and (4)
se ice le els. These le els could o e a way o ac ionalize he complex
p ocess while making i obse able and conc e e h ough benchma king.
Du ing he No dplus Ho izon al p ojec (whe e he design sp in s
desc ibed in his disse a ion we e conduc ed), ou p ojec pa ne s had
a mee ing in Ro aniemi. The ini ial plan was o go on a oad ip o all
h ee loca ions—Tallinn, Go henbu g, and Ro aniemi—and benchma k
he local pa ne hospi als be o e unde aking he ac ual design sp in s.
Due o some di icul ies in inding sui able ime slo s o he oad ip, we
decided o mee in Ro aniemi, lea ing Tallinn ou o ou ip i ine a y.
I was inspi ed by he possibili y o b inging he hospi al expe ience
h ough p o o yping om Tallinn o Ro aniemi. I asked ou pa ne s
om Tallinn o go o he hospi al and ake pic u es so hey could c ea e a
se ice jou ney. I ga e hem ins uc ions on how o ake pic u es so ha
we could walk h ough he hospi al in he simula ion labo a o y (SINCO
– Se ice Inno a ion Co ne ) loca ed a he Uni e si y o Lapland, Facul y
o A and Design (Mie inen, Ron i, Kuu e & Linds öm, 2012; Ron i,
Mie inen, Kuu e & Linds öm, 2012). The expe ience o walking h ough
he local hospi al o Tallinn in he simula ion en i onmen in Ro aniemi
ecei ed a lo o posi i e eedback and showed ha his ype o expe ience
is some hing ha should be de eloped u he (Figu e 22).
Figu e 22. Benchma king h ough se ice p o o yping in SINCO-lab, Uni e si y o
Lapland. (Pic u es: Maileena Tuokko)
Making benchma king mo e ealis ic o he ea ly on -end phase and
showing how he se ices a e un in di e en loca ions o how he de ails
a e s uc u ed can help wi h he s a ing poin . Benchma king is also a
Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
132
ele an me hod o se ice designe s o unde s and he a ia ions o
complex heal hca e se ices and pe cei e he pa ien s’ jou neys and
di e en ac ions om heal hca e p o essionals. Al hough benchma king
is no a new me hod in he heal hca e ield (Kay, 2007), i s ill has huge
po en ial o be e en be e h ough a se ice design app oach. Se ice
design can supply he benchma ked loca ion wi h mo e conc e e,
s o y-based, and imeline- ela ed ac ion, which is easie o unde s and,
expe ience, idea e u he , and, mos o all, accep . In addi ion, he digi al
solu ions o documen ing se ice expe iences will play a c ucial ole in
u u e benchma king. This opic has ue alue and will p o ide g ea
oppo uni ies o u he esea ch.
Ano he a ea o u he esea ch is ela ed o sys ema ic
isualiza ion me hods, linked o benchma king da a om o he hospi als
as well as he hospi al ha is unde de elopmen . The e is a need o go
u he wi h hese me hods, which help o pe cei e a leas he ollowing
a eas: (1) he se ice as a imeline bluep in wi h se ice momen s o
pa ien s, heal hca e p o ide s, and o he c ucial s akeholde s, such as
physio he apis s o social se ice p o ide s; (2) a esou ce bluep in
ha be e mi o s he possibili ies in he de eloped loca ion; and (3)
isualizing he c ucial ouchpoin s so hey a e easie o unde s and and
e en es . Sys ema ic isualiza ion needs mo e esea ch o be amed as a
eady- illed empla e ha i s well wi h di e en hospi al se ice s uc u es.
This will suppo he s a egic ini ia i es o heal hca e.
Finally, I would like o poin ou ha he e a e many possibili ies
o going e en u he wi h design sp in p ocesses ha a e speci ically
designed o he heal hca e ield. He e, I wan o emphasize he oles o
di e en pa icipan s and he skills o acili a o s and ha he design sp in
could be a mon hly, biannual, o annual p ac ice o heal hca e de elopmen .
The design sp in has i s space and ime—wi h he people who a e willing
o be a pa o i being he mos impo an ac o . This could be a g ea
way o implemen design p ac ices, se ice design me hods, and design
hinking as a con en ional p ac ice in he heal hca e ield.

Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design
132 133
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