Early Phase of Healthcare-Related Service Design

Ac a elec onica Uni e si a is Lapponiensis 328 Mi a Alhonsuo    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 4 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 45 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 6 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 67 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 8 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 14 15 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 16 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 17 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 19 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 20 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, Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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 Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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) Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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 Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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 Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 102 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- Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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 Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 104 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 110 111 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 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 Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 116 117 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 Re e encesRe e ences Adams, P. (2003). Thinking skills and cons uc i ism. Teaching Thinking, 10, 50–54. Adams, P. (2006). Explo ing social cons uc i ism: Theo ies and p ac icali ies. Educa ion, 34(3), 243–257. Alam, I. (2006). Remo ing he uzziness om he uzzy on -end o se ice inno a ions h ough cus ome in e ac ions. Indus ial Ma ke ing Managemen , 35(4), 468–480. Alhonsuo, M., & Colley, A. (2019). Designing new hospi als – Who ca es abou he pa ien s? MuC´19: P oceedings o Mensch und Compu e 2019 (pp. 725–729). New Yo k, NY: Associa ion o Compu ing. doi:10.1145/3340764.3344898 Alhonsuo, M., Hookway, S. Sa an ou, M., Mie inen, S., & Mo us, M. (2020). Heal hca e design sp in s: Wha can be changed and achie ed in i e days? In S. Boess, M. Cheung, & R. Cain (Eds.), Syne gy – DRS In e na ional Con e ence 2020, Augus 11–14, 2020 (held online). doi:10.21606/d s.2020. Alhonsuo, M., Sa an ou, M., Hookway, S., Mie inen, S., & Mo us, M. (2020). Pa icipa ion o heal hca e ep esen a i es in heal h- ela ed design sp in s. In J-F. Bouju , G. Cascini, S. Ahmed-K is ensen, G. V. Geo gie , & N. Ii a i (Eds.), P oceedings o he Six h In e na ional Con e ence on Design C ea i i y (ICDC 2020), Augus 26–28, 2020 (pp. 44–51). doi:10.35199/ICDC.2020.06 Almq is , F. (2017). The uzzy on -end and he o go en back-end: Use in ol emen in la e de elopmen phases. The Design Jou nal, 20(1), 2524–2533. Almq is , F. (2019). Se ice design du ing he la e de elopmen phases: In oducing a se ice design oadmapping app oach. In M. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 69–84). Cham, Swi ze land: Sp inge . Almq is , F. (2020). Se ice design in he la e phases: Explo ing use insigh s, hando e s, and se ice design oadmapping in he ansi ion om se ice concep o implemen ed se ice (Doc o al hesis). Oslo School o A chi ec u e and Design, Oslo, No way. Re ie ed om h ps://aho.b age.uni .no/aho-xmlui/handle/11250/2657504 Ban ield, R., Lomba do, C. T. & Wax, T. (2016). Design Sp in : A p ac ical guidebook o building g ea digi al p oduc s. O’Reilly Media. Ba e, P., & Robe , G. (2007). B inging use expe ience o heal hca e imp o emen : The concep s, me hods and p ac ices o expe ience-based design. London, Uni ed Kingdom: Radcli e Publishing. Bax e , P., & Jack, S. (2008). Quali a i e case s udy me hodology: S udy design and implemen a ion o no ice esea che s. The Quali a i e Repo , 13(4), 544–559. Bayazi , N. (2004). In es iga ing design: A e iew o o y yea s o design esea ch. Design Issues, 20(1), 16–29. Bazzano, A. N., & Ma in, J. (2017). Designing public heal h: Syne gy and disco d. The Design Jou nal, 20(6), 735–754. Bei ão, G., Pa ício L., & Fisk, R. P. (2017). Value coc ea ion in se ice ecosys ems: In es iga ing heal h ca e a he mic o, meso, and mac o le els. Jou nal o Se ice Managemen , 28(2), 227–249. Belli eau, P., G i in, A., & Some meye , S. (2004). The PDMA oolbook 2 o new p oduc de elopmen . Hoboken, NJ: Wiley. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 134 Benson, H. R. (1994). An in oduc ion o benchma king in heal hca e. Radiology Managemen , 16(4), 35–39. Be y, L. L., & Bendapudi, N. (2007). Heal h ca e: A e ile ield o se ice esea ch. Jou nal o Se ice Resea ch, 10(2), 111–122. Bes , K. (2006). Design managemen : Managing design s a egy, p ocess and implemen a ion. Lausanne, Swi ze land: AVA Publishing. Bes , K. (2015). Design managemen : Managing design s a egy, p ocess and implemen a ion (2nd ed.). New Yo k, NY: Bloomsbu y Publishing. Binde , T., B and , E., & G ego y, J. (2008). Edi o ial: Design pa icipa ion(-s). CoDesign, 4(1), 1–3. Bisman, J. E., & High ield, C. (2012). The oad less a elled: An o e iew and example o cons uc i is esea ch in accoun ing. Aus alasian Accoun ing, Business and Finance Jou nal, 6(5), 3–22. Bi ne , M. J., Booms, B. H., & Te eaul , M. S. (1990). The se ice encoun e : Diagnosing a o able and un a o able inciden s. Jou nal o Ma ke ing, 54(1), 71–84. Bi ne , M. J., Os om, A. L., & Mo gan, F. N. (2008). Se ice bluep in ing: A p ac ical echnique o se ice inno a ion. Cali o nia Managemen Re iew, 50(3), 66–94. Blomk is , J. (2012). Concep ualisa ions o se ice p o o yping: Se ice ske ches, walk h oughs and li e se ice p o o ypes. In S. Mie inen & A. Val onen (Eds.), Se ice design wi h heo y. Discussion on alue, socie al change and me hods (pp. 177–188). Ro aniemi, Finland: Lapland Uni e si y P ess. Blomk is , J. (2014). Rep esen ing u u e si ua ions o se ice: P o o yping in se ice design (Doc o al hesis). Linköping Uni e si y, Linköping, Sweden. Re ie ed om h ps:// www.di a-po al.o g/smash/ge /di a2:712357/FULLTEXT02.pd Blomk is , J. (2016). Bene i s o se ice le el p o o yping. The Design Jou nal, 19(4), 545–564. Blomk is , J., & Bode, A. (2012). Using se ice walk h oughs o co-c ea e whole se ice expe iences. Pape p esen ed a he 3 d In e na ional Se ice Inno a ion Design Con e ence in Tainan, Taiwan, Oc obe 22–24, 2012. Blomk is , J., Holmlid, S., & Segels öm, F. (2010). Se ice design esea ch: Yes e day, oday and omo ow. In M. S ickdo n & J. Schneide (Eds.), This is se ice design hinking (pp. 308–315). Ams e dam, Ne he lands: BIS Publishe s. Booz, Allen & Hamil on. (1982). New p oduc s managemen o he 1980s. New Yo k, NY: Booz, Allen & Hamil on, Inc. Bowen, S., McSe eny, K., Lockley, E., Wols enholme, D., Cobb, M., & Dea den, A. (2013). How was i o you? Expe iences o pa icipa o y design in he UK heal h se ice. CoDesign, 9(4), 230–246. Boyd, H., McKe non, S., Mullin, B., & Old, A. (2012). Imp o ing heal hca e h ough he use o co-design. The New Zealand Medical Jou nal, 125(1357), 76–87. B edies, K. (2016). In oduc ion. In G. Joos , K. B edies, M. Ch is ensen, F. Con adi, & A. Un eidig (Eds.), Design as esea ch: Posi ions, a gumen s, pe spec i es (pp. 12–16). Basel, Swi ze land: Bi khäuse . Buchanan, R. (1992). Wicked p oblems in design hinking. Design Issues, 8(2), 5–21. Bu ns, C., Co am, H., Vans one, C., & Winhall, J. (2006). T ans o ma ion design. London, Uni ed Kingdom: Design Council. Re ie ed om h ps://www.designcouncil.o g.uk/ si es/de aul / iles/asse /documen / ed-pape - ans o ma ion-design.pd Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 134 135 Canham, A., Jun, G. T., & Selby, A. (2016). Towa ds e ec i e and e icien pa icipa o y sys ems app oaches o heal hca e wo k sys em design. The 2016 Heal hca e Sys ems E gonomics and Pa ien Sa e y Con e ence (HEPS), Oc obe 5–7, 2016, Toulouse, F ance. h ps:// hdl.handle.ne /2134/2597 Clack, L. A., & Ellison, R. L. (2019). Inno a ion in se ice design hinking. In M. A. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 85–92). Cham, Swi ze land: Sp inge . Cla wo hy, S. (2010). Se ice inno a ion h ough ouch-poin s: The AT-ONE ouch-poin ca ds. P oceedings o Se Des con e ence, Linköping, Sweden, Decembe 1–3, 2010, 25–38 Cla wo hy, S. (2013). Design suppo a he on end o he New Se ice De elopmen (NSD) p ocess (Doc o al disse a ion). The Oslo School o A chi ec u e and Design, Oslo, No way. Re ie ed om h ps://co e.ac.uk/download/pd /52039961.pd Coope , R., & Kleinschmid , E. (1986). Benchma king he i m’s c i ical success ac o s in new p oduc de elopmen . Jou nal o P oduc Inno a ion Managemen , 3(3), 71–85. Coughlan, P., Ful on Su i, J., & Canales, K. (2007). P o o ypes as (design) ools o beha io al and o ganiza ional change. A design-based app oach o help o ganiza ions change wo k beha io s. The Jou nal o Applied Beha io al Science, 43(1), 1–13. C eswell, J. W. (2014). Resea ch design. Quali a i e, quan i a i e, and mixed me hods app oaches (4 h ed.). London, Uni ed Kingdom: SAGE Publishing. C eswell, J. W., & C eswell, J. D. (2018). Resea ch design. Quali a i e, quan i a i e and mixed me hods app oaches (5 h ed.). Thousand Oaks, CA: SAGE Publishing. C oss, N. (2007). Designe ly ways o knowing. Boa d o In e na ional Resea ch in Design. Basel, Swi ze land: Bi khäuse . C o y, M. (1998). The ounda ions o social esea ch: Meaning and pe spec i e in he esea ch p ocess. Thousand Oaks, CA: SAGE Publishing. Design Council. (2015). Inno a ion by design: How design enables science and echnology esea ch o achie e g ea e impac . Re ie ed om h p://www.designcouncil.o g.uk/ si es/de aul / iles/asse /documen /inno a ion-by-design.pd Dewey, J. (1933). How we hink: A es a emen o he ela ion o e lec i e hinking o he educa i e p ocess. Bos on, MA: DC Hea h. Doldo , E., Sil es e , J., & A ewologun, D. (2017). Quali a i e me hods in o ganiza ional psychology. In W. S. Roge s & C. Willig (Eds.), The SAGE handbook o quali a i e esea ch in psychology (pp. 520–540). Thousand Oaks, CA: SAGE Publishing. Done o, S., Pie i, P., Tsianakas, V., & Robe , G. (2015). Expe ience-based co-design and heal hca e imp o emen : Realizing pa icipa o y design in he public sec o . The Design Jou nal, 18(2), 227–248. Do s , K. (2008). Design esea ch: A e olu ion-wai ing- o-happen. Design S udies, 29(1), 4–11. Edmondson, A. C. (2004). Lea ning om ailu e in heal h ca e: F equen oppo uni ies, pe asi e ba ie s. Quali y and Sa e y in Heal h Ca e, 13(Suppl. II), ii3–ii9. Ed a dsson, B., Gus a sson, A., Johnson, M. D., & Sandén, B. (2000). New se ice de elopmen and inno a ion in he new economy. Lund, Sweden: S uden li e a u . Ed a dsson, B., Gus a sson, A., & Roos, I. (2005). Se ice po ai s in se ice esea ch: A c i ical e iew. In e na ional Jou nal o Se ice Indus y Managemen , 16(1), 107–121. Findeli, A. (1999). In oduc ion. Design Issues, 15(2), 1-3. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 136 Foglieni, F., Sega o, F., Sangio gi, D., & Ca e a, M. (2019). E alua ing co-p oduc ion in men al heal h se ices as a suppo o co-design ac i i ies. In M. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 189–200). Cham, Swi ze land: Sp inge . Foglieni, F., Villa i, B., & Ma ei, S. (2017). Designing be e se ices: A s a egic app oach om design o e alua ion. Cham, Swi ze land: Sp inge . F ayling, C. (1993). Resea ch in a and design. Royal College o A Resea ch Pape s, 1(1), 1–5. F ei e, K., & Sangio gi, D. (2010). Se ice design and heal hca e inno a ion: F om consump ion o co-p oduc ion o co-c ea ion. In S. Cla wo hy, J. V. Nisula, & S. Holmlid (Eds.), Se Des Con e ence p oceedings (pp. 39–50), Decembe 1–3, 2010, Linkoping, Sweden. F y, K. R. (2019). Why hospi als need se ice design. In M. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 377–399). Cham, Swi ze land: Sp inge . Gamba o , V., Sa no, D., Hysa, X., Calab ese, M., & Bilo a, A. (2017). The ole o loyal y p og ams in heal hca e se ice ecosys ems. The TQM Jou nal, 29(6), 899–919. Ga e , W., & Dunne, A., & Pacen i, E. (1999). Design: Cul u al p obes. In e ac ions, 6(1), 21–29. Gleason, B., & Bohn, J. (2017). Essen ial cha ac e is ics o se ice business model inno a ion in heal hca e: A case-s udy app oach. In M. P anns iel & C. Rasche C. (Eds.), Se ice Business Model Inno a ion in Heal hca e and Hospi al Managemen (pp. 137–158). Cham, Swi ze land: Sp inge . Golds ein, S. M., Johns on, R., Du y, J., & Rao, J. (2002). The se ice concep : The missing link in se ice design esea ch? Jou nal o Ope a ions Managemen , 20(2), 121–134. Goodwin, S. (2020). Meaning ul heal hca e expe ience design: Imp o ing ca e o all gene a ions. New Yo k, NY: P oduc i i y P ess. Guba, E. G., & Lincoln, Y. S. (1994). Compe ing pa adigms in quali a i e esea ch. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook o quali a i e esea ch (pp. 105–117). Thousand Oaks, CA: SAGE Publica ions. Hakio, K., & Ma elmäki, T. (2011). Design ad en u es in he public sec o . DPPI´11: P oceedings o he 2011 Con e ence on Designing Pleasu able P oduc s and In e aces (pp. 1–8). Associa ion o Compu ing Machine y, New Yo k, NY, USA. doi:10.1145/2347504.2347570 He io . R. (2018). Pa ien in ol emen in Danish hospi al design. CoDesign 14(3), 203–217. Hemmings, T., C ab ee, A., Rodden, T., Cla ke, K., & Rounce ield, M. (2002). P obing he P obes. P oceedings o he Pa icipa o y Design Con e ence 2002 (pp. 40–50). Palo Al o, CA: CPSR. Higgings, I. (1997). Benchma king in heal h ca e: A e iew o he li e a u e. Aus alian Heal h Re iew, 20(4), 60–69. Holmlid, S., & E enson, S. (2008). B inging se ice design o se ice sciences, managemen and enginee ing. In B. He ey & W. Mu phy (Eds.), Se ice science, managemen and enginee ing: Educa ion o he 21s cen u y (pp. 341–345). Bos on, MA: Sp inge . Holmlid, S., & Malmbe g, L. (2018). Lea ning o design in public sec o o ganiza ions: A c i ique owa ds e ec i eness o design in eg a ion. P oceedings o Se Des2018. Se ice Design P oo o Concep , June 18–20, 2018, Milan, I aly (pp. 37–48). Linköping, Sweden: Linköping Uni e si y Elec onic P ess. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 142 143 S ickdo n, M., Ho mess, M., Law ence, A., & Schneide , J. (2018). This is se ice design doing: Applying se ice design hinking in he eal wo ld: A p ac i ione ’s handbook. New on, MA: O’Reilly Media, Inc. S ickdo n, M., & Schneide , J. (2011). This is se ice design hinking: Basics, ools, cases. Ams e dam, Ne he lands: BIS Publishe s. Sun, Q. (2020). Towa ds a new agenda o se ice design esea ch. The Design Jou nal, 23(1), 49–70. Suoheimo, M. (2020). App oaching wicked p oblems in se ice design (Doc o al disse a ion). Ac a Elec onica Uni e si a is Lapponiensis 286. Ro aniemi, Finland: Lapland Uni e si y P ess. T ischle , J., & Cha les, M. (2019). The applica ion o a se ice ecosys ems lens o public policy analysis and design: Explo ing he on ie s. Jou nal o Public Policy & Ma ke ing, 38(1), 19–35. T ischle , J., Die ich, T., & Rundle-Thiele, S. (2019). Co-design: F om expe - o use -d i en ideas in public se ice design. Public Managemen Re iew, 21(11), 1595–1619. Vaajakallio, K., Lee, J-J., K onq is , J., & Ma elmäki, T. (2013). Se ice co-design wi h he public sec o – Challenges and oppo uni ies in a heal hca e con ex . The 7 h Con e ence o Include Asia. Re ie ed om h p://include13.kine ixe en s.co.uk/ ca/ ca2013/ pape _ inal/F1113_4459.PDF Valen ine, L., K oll, T., B uce, F., Lim, C., & Moun ain, R. (2017). Design hinking o social inno a ion in heal h ca e. The Design Jou nal, 20(6), 755–774. Va go, S. L., & Akaka, M. A. (2012). Value coc ea ion and se ice sys ems ( e) o ma ion: A se ice ecosys ems iew. Se ice Science, 4(3), 207–217. Va go, S. L., & Lusch, R. F. (2004). E ol ing o a new dominan logic in ma ke ing. Jou nal o Ma ke ing, 68, 1–17. Va go, S., & Lusch, R. (2008). Se ice-dominan logic: Con inuing he e olu ion. Jou nal o he Academy o Ma ke ing Science, 36(1), 1–10. Va go, S. L., & Lusch, R. F. (2017). Se ice-dominan logic 2025. In e na ional Jou nal o Resea ch in Ma ke ing, 34(1), 46–67. Vechakul, J., Sh imali, B. P., & Sandhu, J. S. (2015). Human-cen e ed design as an app oach o place-based inno a ion in public heal h: A case s udy om Oakland, Cali o nia. Ma e nal and Child Heal h Jou nal, 19(12), 2552–2559. Ve e li C., & Sche e , C. (2019). Se ice inno a ion by pa ien -cen ic inno a ion p ocesses. In M. A. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 55–67). Cham, Swi ze land: Sp inge . Vink, J., Joly, M. P., We e -Edman, K., T on oll, B., & Ed a dsson, B. (2019). Changing he ules o he game in heal hca e h ough se ice design. In M. A. P anns iel & C. Rasche (Eds.), Se ice design and se ice hinking in heal hca e and hospi al managemen : Theo y, concep s, p ac ice (pp. 19–37). Cham, Swi ze land: Sp inge . Vog , J. W. (2009). Recha ge you eam: The g ounded isioning app oach. Wes po , CT: P aege Publishe s. Wang, V., Lee, S. Y. D., & Maciejewski, M. L. (2015). Ine ia in heal hca e o ganiza ions: A case s udy o pe i oneal dialysis se ices. Heal hca e Managemen Re iew, 40(3), 203–213. Wes , K. (2021). Benchma king in heal hca e: De ini ion, ypes & bene i s. Re ie ed om h ps://s udy.com/academy/lesson/benchma king-in-heal hca e-de ini ion- ypes- bene i s.h ml Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 144 We e -Edman, K., Sangio gi, D., Ed a dsson, B., Holmlid, S., G ön oos, C., & Ma elmäki, T. (2014). Design o alue co-c ea ion: Explo ing syne gies be ween design o se ice and se ice logic. Se ice Science, 6(2), 106–121. We e -Edman, K., Vink, J., & Blomk is , J. (2018). S aging aes he ic dis up ion h ough design me hods o se ice inno a ion. Design S udies, 55, 5–26. Wols enholme, D., Cobb, M., Bowen, S., W igh , P., & Dea den, A. (2010). Design-led se ice imp o emen o olde people. Aus alasian Medical Jou nal, 3(8), 465–470. Yang, L., & Ge gen, K. (2012). Social cons uc ion and i s de elopmen : Liping Yang in e iews Kenne h Ge gen. Psychological S udies, 57(2), 126–133. Yin, R. K. (2009). Case s udy esea ch: Design and me hods. Thousand Oaks, CA: SAGE Publishing. Yin, R. K. (2014). Case s udy esea ch. Design and me hods (5 h ed.). Thousand Oaks, CA: SAGE Publishing. Yu, E., & Sangio gi, D. (2014). Se ice design as an app oach o new se ice de elopmen : Re lec ions and u u e s udies. Se Des Fou h Se ice Design and Inno a ion Con e ence “Se ice Fu u es” (pp. 194–204). Lancas e , Uni ed Kingdom. Yu, E., & Sangio gi, D. (2017). Se ice design as an app oach o implemen he alue coc ea ion pe spec i e in new se ice de elopmen . Jou nal o Se ice Resea ch, 21(1), 40–58. Yu, E., & Sangio gi, D. (2018). Explo ing he ans o ma i e impac s o se ice design: The ole o designe –clien ela ionships in he se ice de elopmen p ocess. Design S udies, 55, 79–111. Zahay, D., G i in, A., & F ede icks, E. (2004). Sou ces, uses, and o ms o da a in he new p oduc de elopmen p ocess. Indus ial Ma ke ing Managemen , 33(7), 657–666. h ps://doi.o g/10.1016/J.INDMARMAN.2003.10.002 Zimme man, J., S ol e man, E., & Fo lizzi, J. (2010). An analysis and c i ique o esea ch h ough design: Towa ds a o maliza ion o a esea ch app oach. P oceedings o he 8 h ACM Con e ence on Designing In e ac i e Sys ems (DIS ‘10). (pp. 310–319). Associa ion o Compu ing Machine y, New Yo k, NY, USA. Alhonsuo: Ea ly Phase o Heal hca e-Rela ed Se ice Design 144 145