Early Phase of Healthcare-Related Service Design

Acta electronica Universitatis Lapponiensis 328 Mira Alhonsuo    Alhonsuo: Early Phase of Healthcare-Related Service Design 1 Acta electronica Universitatis Lapponiensis 328 MIRA ALHONSUO Early Phase of Healthcare-Related Service Design Academic dissertation to be publicly defended with the permission of the Faculty of Art and Design at the University of Lapland in Esko ja Asko hall on 10 December 2021 at 12 noon. Rovaniemi 2021 Alhonsuo: Early Phase of Healthcare-Related Service Design Copyright license: CC BY-NC 4.0 Cover art: Martta Kivekäs Layout: Mira Alhonsuo Acta electronica Universitatis Lapponiensis 328 ISBN 978-952-337-296-2 ISSN 1796-6310 Permanent address to the publication: http://urn.fi/URN:ISBN:978-952-337-296-2 University of Lapland Faculty of Art and Design Supervised by Professor Satu Miettinen, University of Lapland Doctor Melanie Sarantou, University of Lapland Emerita Professor Kaarina Määttä, University of Lapland Reviewed by Doctor and Lead Service Designer Kirsikka Vaajakallio, Hellon Service Design Agency Katja Battarbee, Doctor of Arts, Apple Opponent Doctor and Lead Service Designer Kirsikka Vaajakallio, Hellon Service Design Agency Alhonsuo: Early Phase of Healthcare-Related Service Design Alhonsuo: Early Phase of Healthcare-Related Service Design 4 AbstractAbstract Healthcare organizations are under constant pressure to develop and reform. The object to be developed may vary from the hospital’s signs to national social and healthcare reforms. Service design and co-design provide one way to research and develop healthcare services. These different ways of approaching development can support and inspire people to participate in the development process. This research focused on examining the early phase of healthcarerelated service design and determining what is needed before starting an actual design process in a healthcare organization. The focus was narrowed to looking at the perspectives of healthcare professionals as well as how they can be introduced to service design and co-design and, thus, how to arouse their interest in design-driven development activities. These perspectives generated the main research question: How can service design and co-design approaches support the early phase of healthcarerelated service development? This article-based research is grounded in constructivism and encompasses a qualitative research project using case study and ethnography as the methodological choices. The research was carried out through four sub-studies, formulated as academic publications. Sub-study I investigated service design tools and collaborative practices used to support and develop customer journeys and hospital management practices. Sub-study II aimed to understand how patients’ experiences and co-design methods were used in the pre-construction phase of a new hospital. Sub-studies III and IV were conducted through three design sprints and assessed, for instance, the involvement of healthcare professionals as part of the design sprints and what were the strengths and weaknesses of the design sprints, especially in relation to the development of healthcare services. The findings from these sub-studies yielded the following conclusions. First, benchmarking is an important process both for developing hospital management practices and for selecting efficient design-based methods during the development process. Second, design methods are a way to create and share a vision, understand service Alhonsuo: Early Phase of Healthcare-Related Service Design 45 ecosystems, concretize services, and gather evidence of the benefits of service design and co-design. Third, the pressured timescale and limited healthcare resources challenge participation in co-design and the usage of design methods. Lastly, the design sprint in healthcare is an efficient process for knowledge and information sharing, understanding the design process, learning different design methods, and creating synergy among stakeholders. Design sprints can, therefore, be seen as an intensive introduction to the service design field and co-design. The principle result of this research is a practical framework for the early phase of healthcare-related service design – before the actual development process. The framework introduces three main sub-phases: benchmarking, preparation, and design sprint. The framework allows for observing the different levels of service ecosystems, clarifying the early phase of healthcare-related service design, such as the dimensions of the service to be developed and the resources needed during the development process, and discussing the design methods suitable for everyday work. Keywords: service design, co-design, healthcare service development, design process, design sprint Alhonsuo: Early Phase of Healthcare-Related Service Design 6 TiivistelmäTiivistelmä Terveydenhuollon organisaatiot ovat jatkuvien uudistuspaineiden alla. Kehitettävän kohteen mittasuhteet voivat vaihdella sairaalan opastauluista valtakunnallisiin sosiaalija terveydenhuollon uudistuksiin. Palvelumuotoilu ja yhteissuunnittelu tarjoavat yhden tavan tutkia ja kehittää terveydenhuollon palveluita. Nämä erilaiset kehittämisen tavat voivat tukea ja innostaa ihmisiä osallistumaan kehittämisen prosessiin. Väitöskirjassa tutkittiin terveydenhuollon palveluiden kehittämisprosessin alkuvaihetta terveydenhuollon organisaatiossa. Tutkimus rajattiin erityisesti terveydenhuollon ammattilaisten näkökulmiin, sekä siihen, millä tavoin ammattilaiset voidaan tutustuttaa palvelumuotoiluun ja yhteissuunnitteluun, ja miten herätetään heidän kiinnostuksensa muotoilulähtöiseen kehittämistoimintaan. Tästä lähtökohdasta syntyi tutkimuksen pääkysymys: miten palvelumuotoilun ja yhteissuunnittelun lähestymistavat voivat tukea terveydenhuoltopalveluiden kehittämisen alkuvaihetta? Väitöskirja on artikkelipohjainen. Sitä ohjaa konstruktivistinen paradigma. Tutkimusstrategia on laadullinen, ja sen metodologisia valintoja ovat etnografia ja tapaustutkimus. Väitöstutkimus on jaettu artikkeleiden mukaan neljäksi osatutkimukseksi. Ensimmäisessä osatutkimuksessa tarkasteltiin palvelumuotoilun työkaluja ja yhteissuunnittelun tapoja sairaalan johtamiskäytäntöjen tukemisessa ja kehittämisessä. Toisen osatutkimuksen tavoitteena oli ymmärtää, miten potilaiden kokemukset ja yhteissuunnittelun menetelmät on otettu huomioon sairaalanrakennusprojektin esisuunnitteluvaiheessa. Kolmannessa ja neljännessä osatutkimuksessa toteutettiin kolme muotoilusprinttiä. Niiden kautta tarkasteltiin muun muassa terveydenhuollon ammattilaisten osallisuutta osana muotoilusprinttiä sekä sitä, mitkä ovat muotoilusprinttien vahvuudet ja heikkoudet erityisesti terveydenhuollon palveluiden kehittämisessä. Näiden osatutkimusten kautta kiteytyivät vastaukset tutkimuskysymyksiin. Tutkimustuloksina kyettiin osoittamaan, että vertailuanalyysi, eli benchmarking, on tärkeä prosessi niin sairaalan Alhonsuo: Early Phase of Healthcare-Related Service Design 67 johtamiskäytäntöjen kehittämisessä kuin toimivien muotoilulähtöisten menetelmien valinnassa kehittämisprosessin aikana. Muotoilun menetelmät osoittautuivat tavaksi luoda ja jakaa visioita, ymmärtää palveluekosysteemejä, konkretisoida palveluja ja kerätä todisteita palvelumuotoilun ja yhteissuunnittelun hyödyistä. Tulokset osoittavat, että aikataulupaineet ja rajalliset terveydenhuollon resurssit hankaloittavat yhteissuunnitteluun osallistumista ja muotoilun menetelmien käyttöönottoa. Terveydenhuollon muotoilusprinttien avulla voitiin edistää tiedon jakamista, muotoiluprosessin ymmärtämistä, erilaisten muotoilun menetelmien oppimista sekä sidosryhmien välisen synergian rakentamista. Muotoilusprintit voidaankin nähdä intensiivisenä johdatuksena palvelumuotoiluun ja yhteissuunnitteluun. Tutkimuksen päätuloksena luotiin käytännönläheinen viitekehys terveydenhuollon palvelumuotoilun alkuvaiheen tueksi – ennen virallisen kehittämisprosessin käynnistämistä. Viitekehys muodostuu kolmesta vaiheesta: vertailuanalyysi (benchmarking), valmistelu ja muotoilusprintti. Viitekehyksen avulla voidaan tarkastella palveluekosysteemien eri tasoja sekä sitä, miten alkuvaiheen suunnittelua voidaan selkeyttää esimerkiksi tarkastelemalla kehitettävän palvelun mittasuhteita ja kehittämisprosessin aikana tarvittavia resursseja sekä työarkeen soveltuvia muotoilun menetelmiä. Avainsanat: palvelumuotoilu, yhteissuunnittelu, terveydenhuollon palveluiden kehittäminen, muotoiluprosessi, muotoilusprintti Alhonsuo: Early Phase of Healthcare-Related Service Design 8 Acknowledgments Acknowledgments This academic journey has planted lifelong roots that keep me standing even in a high wind. These roots have grown strong and long. I would like to take this opportunity to thank those whose existence has been significant on the journey and who, with their own skills and essences, have strengthened my roots. These words are the final written rows in my dissertation but are definitely the most important to me. With a warm heart, I would like to thank the following people. I have been lucky to have three intelligent supervisors, who are strong and empathetic women, to guide my dissertation. Thank you, Professor Satu Miettinen. You have supported me from the beginning and believed in me. You’ve given me enough freedom to take my own path but have shown directions whenever my compass hasn’t known which way to point. You have shown me places from which I have drawn experiences and created important relationships for the future. I am forever grateful for these opportunities and moments together. Thank you, Emerita Professor Kaarina Määttä. You came along in the final stages of my dissertation process, when my head was full of more or less fuzzy ideas. You taught me to think more clearly, to believe in myself, and to trust that my research was almost complete, even though I still had a long way to go. Your positive essence has left me with good memories. Finally, the most important and significant woman on my research journey is Adjunct Professor Melanie Sarantou. I got to know you at the beginning of my postgraduate studies, when I was looking for myself and I was already changing direction. You pointed me toward the paths I could walk. You’ve been there when I’ve been lost and brought me forward. You have been a piece of gold on this journey, and there are not enough words to say how grateful I am to you. Thank you, Melanie! I had two wonderful individuals as pre-examiners of my dissertation. Thank you, Dr. Kirsikka Vaajakallio, for your insightful thoughts. I felt that I had succeeded and grown more as a researcher. Thank you for agreeing to be my opponent—to share a discussion about experiences that have also been significant and important in your work. Thank you, Alhonsuo: Early Phase of Healthcare-Related Service Design 14 15 Figure 14. Examples of a visualized service concepts created for families and healthcare professionals during the case-study 2 in substudy I. (Author’s illustrations) Figure 15. Design sprint process in Gothenburg, Sweden. Figure 16. Design sprint process in Tallinn, Estonia. Figure 17. Design sprint process in Rovaniemi, Finland. Figure 18. Mentoring during the design sprints in Rovaniemi. (Pictures: Maileena Tuokko) Figure 19. Facilitation in the practice in the design sprint in Rovaniemi. In the picture on the left, I am negotiating with the coordinator from the hospital. In the picture on the right, I am listening to and observing the design sprint team members. (Pictures: Maileena Tuokko) Figure 20. Overview of the practical framework “Pre-phase for healthcare service development” as part of the design process for service development. (Author’s illustration) Figure 21. Pre-phase for healthcare service development framework and the service ecosystem levels. (Author’s illustration) Figure 22. Benchmarking through service prototyping in SINCO-lab, University of Lapland. (Pictures: Maileena Tuokko) Tables: Table 1. Summary of sub-study I. Table 2. Summary of sub-study II. Table 3. Summary of sub-study III. Table 4. Summary of sub-study IV. Table 5. Strengths and weaknesses from design sprint participants’ perspectives. Table 6. Key findings from sub-study I. Table 7. Key findings from sub-study II. Table 8. Key results from sub-study III. Table 9. Key findings from sub-study IV. Table 10. The three steps of preliminary preparations from the viewpoint of objectives. Table 11. The three steps of preliminary preparations from the viewpoint of impacts and value. Table 12. The three steps of preliminary preparations from the viewpoint of design tools and methods. Alhonsuo: Early Phase of Healthcare-Related Service Design 16 Abstract ..................................................................................................................4 Tiivistelmä .............................................................................................................6 Acknowledgments ..............................................................................................8 List of Original Publications and the Author’s Contributions ...... 12 List of Figures and Tables ............................................................................. 14 Table of Contents ............................................................................................. 16 1. Introduction .............................................................................................19 1.1. Research Focus and Context .............................................................19 1.2. My Research Journey ..........................................................................24 1.3. Research Questions and Aims ...........................................................27 1.4. Research Limitations ..........................................................................29 1.5. Structure of the Dissertation .............................................................30 2. Theoretical Background .......................................................................33 2.1. Service Design .....................................................................................33 2.1.1. Role of the Service Designer ...................................................37 2.1.2. Different Processes in Design and Development .................40 2.1.3. Interplay between Different Service Levels ...........................49 2.2. Co-design .............................................................................................53 2.3. Healthcare Services .............................................................................56 2.3.1. Change in Healthcare Organizations .....................................57 2.3.2. Healthcare Development .........................................................60 3. Research Design ......................................................................................65 3.1. Research through Design ...................................................................65 3.2. Constructivism ....................................................................................69 3.3. Research Strategies and Methodological Choices ..........................70 Table of ContentsTable of Contents Alhonsuo: Early Phase of Healthcare-Related Service Design 17 16 3.4 Data Collection Methods and Analyses of the Sub-Studies ...........73 3.4.1. Sub-Study I ................................................................................76 3.4.2. Sub-Study II ...............................................................................83 3.4.3. Sub-Studies III and IV .............................................................83 3.5. Ethical Considerations and Evaluations ..........................................89 3.6. Reflexivity of the Research .................................................................93 4. Results.........................................................................................................95 4.1. Service Design Tools as Supporting and Developing Hospital Management Practices........................................................95 4.1.1. Benchmarking as a Process to Develop Hospital Management Practices .............................................95 4.1.2. Design Methods as a Way to Create and Share a Vision and Understand Ecosystems .......................................98 4.2. Patients’ Experiences of Healthcare Services ..................................99 4.3. Strengths and Weaknesses of Health-Related Design Sprints .....102 4.4. Healthcare Representatives as Supporting Design Sprints in Healthcare Services ......................................................................106 4.5. Summary of the Key Findings .........................................................110 5. Discussion ...............................................................................................115 5.1. Preliminary Preparation and Evidence ..........................................115 5.2. Familiarization with the Unknown ................................................118 5.3. Practical Framework for Healthcare Service Development ........120 5.3.1. Practical Framework and Service Ecosystem Levels ..........123 6. Conclusions ............................................................................................129 6.1. Impacts of the Research ...................................................................129 6.2. Suggestions for Further Research ...................................................130 References .........................................................................................................133 Alhonsuo: Early Phase of Healthcare-Related Service Design Picture: Maileena Tuokko Alhonsuo: Early Phase of Healthcare-Related Service Design 19 1. Introduction 1.1. Research Focus and Context Healthcare is a complex field of multi-layered processes, varieties of actions, and people with different backgrounds and expertise (Bowen et al., 2013). As a service, it is universally used and has an impact on our economies and quality of life (Berry & Bendapudi, 2007), and it tackles, for instance, continuing growth, the aging population, service reforms, new technologies, and above all, internal and external pressures to change (Fry, 2019). These challenges push healthcare toward more innovative solutions, which often might be difficult to implement not only due to organizational resistance to change (Vink, Joly, Wetter-Edman, Tronvoll, & Edvardsson, 2019; Wang, Lee, & Maciejewski, 2015) but also a lack of focused and secure management (Fry, 2019; Nilsen, Dugstad, Eide, Gullslett, & Eide, 2016). These challenges can also be seen as “wicked problems” that are difficult or impossible to solve. That is, as there are no unambiguous criteria or agreement on the solution among stakeholders, it is difficult to say when a problem is solved, and there is no option to revert the solutions to the former phase (e.g., Rittel & Webber, 1973). Although wicked problem is already an established term in design, in this research, I am generally talking about complex services. Design and healthcare have had a long history together in healthcare improvement (Rowe, Knox, & Harvey, 2020). The objective of healthcarerelated development can vary significantly and may consist of the physical architecture and interior design or the holistic service journey from the patient’s perspective and the different touchpoints related to the service. It may also consist of all of the above elements together, where the service Alhonsuo: Early Phase of Healthcare-Related Service Design 20 itself is not confined to the clinical encounters and physical boundaries of the building but extends to a large number of different interfaces and interactions (Wolstenholme, Cobb, Bowen, Wright, & Dearden, 2010). This is a good illustration of how multi-leveled and complex healthcare services are. Public healthcare has already applied patient involvement and co-design approaches (Nesta, 2013), but heavy pressure is put on designers and their success in “creating something that does not yet exist” (Nelson & Stolterman, 2012, p. 28). Although many studies present evolving but nevertheless critical perspectives on the development of healthcare services, there remains much work to be done to determine how service design and co-design approaches could support healthcare-related development even further. Previous studies have discussed where service design should have its place and impact in the development process (e.g., Almqvist, 2017, 2020; Clatworthy, 2013; Raun, 2017 ; Yu & Sangiorgi, 2014). In fact, some of the recent literature has noted that the early phase of the design process, the so-called fuzzy front end, has already been investigated and received a lot of attention (Alam, 2006; Almqvist, 2017, 2019; Clatworthy, 2013; Raun, 2017), and it is, therefore, time to focus on the later phases where implementation occurs, because design has not reached the desired capacity (Holmlid & Malmberg, 2018; Malmberg, 2017). However, the front end is the most information intensive. Here, different types of information from internal and external sources are brought into the project (Zahay, Griffin, & Fredricks, 2004), the major decisions are made (Clatworthy, 2013), and, for instance, teams and stakeholders get to know not only the given brief but also each other. I believe that there are opportunities for development in the early phase of the design process to engage stakeholders and facilitate their participation in service design and co-design and, thus, drive change in healthcare organizations. A change in healthcare is truly needed (Bate & Robert, 2007; Fry, 2019; Jones, 2013) , but there is no standard or equal way to approach these changes. As highlighted in the literature, change and transformation in an organization happen through learning (Kuure, Miettinen, & Alhonsuo, 2014), and staff management is necessary when changes must be adopted and implemented in the healthcare staff’s work life (e.g., Nilsen et al., 2016; Stickdorn & Schneider, 2011), but despite this, there is no one way to approach the changes. In design, the processes cannot be standardized due to the very different needs for development and multi-layered and siloed service structures. However, when aiming for change in complex organizations, such as healthcare organizations, we need to understand the Alhonsuo: Early Phase of Healthcare-Related Service Design 20 21 service ecosystem, which is impossible to design in its entirety including contexts and actors (Polaine, Løvlie, & Reason, 2013). By outlining the levels of different service ecosystems, we can understand more precisely the different layers and the relationships between them. This research has broken down the field of development into three different service ecosystem levels to support healthcare-related service development. These service ecosystem levels are, as Beirão, Patrício, and Fisk (2017) has formulated, the micro, meso, and macro levels. Here, the micro level focuses on physicians and customer exchange services, service touchpoints, and situations within a hospital. The meso level considers hospital and other healthcare organization interactions, which can be at the regional and local levels and involve public and private sector collaboration. The most challenging level is the macro level, which incorporates the national level with the government and Ministry of Health. The division into service ecosystem levels facilitates perceiving different and complex healthcare services, and consequently, the achievement of objectives is more realistic. In any case, practical approaches are needed to perceive these levels and to understand the values of service design and co-design. Therefore, this research proposes an alternative approach. This research specifically focuses on and examines the early phase of healthcare-related service design to determine what is needed before starting an actual design process for healthcare service development in an organization and integrating people from different backgrounds and with different expertise. It focuses on the phase even earlier than the so-called fuzzy front end (e.g., Cooper & Kleindschmidt, 1986; Smith & Reinertsen, 1998). I am interested in seeking ways to interest hospitals in what service design and design tools can enable in healthcare service development and, through that, bring patients, relatives, and others into co-design cycles and develop better healthcare experiences for the future. I have realized that something needs to be done before the actual healthcare service design process can start—a process in which end users (e.g., patients or family members) and other important stakeholders are more closely involved in the co-design. There is a crucial phase at the beginning of service development that should be dedicated to people working in healthcare sector, such as doctors, nurses, support staff, and management. The phase focused on understanding, evidence gathering, learning, and knowing each other is the phase that I will discuss in more detail in this dissertation. Intertwined around this challenge are four academic articles that together form the practical framework that is the principle result of this research. These academic articles highlight three main theories: service Alhonsuo: Early Phase of Healthcare-Related Service Design 22 design, co-design, and healthcare services. Service design has been a natural part of my research since the early stages of my career, but it also provides a strong theoretical field for service development, and thus, also has strong roots in this research. Co-design is widely used in the healthcare domain to understand the bigger picture of the field (e.g., Pirinen, 2016; Trischler, Dietrich, & Rundle-Thiele, 2019; Vaajakallio, Lee, Kronqvist, & Mattelmäki, 2013) and requires creative initiative from the teams, which include researchers, designers, and other important stakeholders, who are “experts of their experiences” (Sleeswijk Visser, Stappers, Van der Lugt, & Sanders, 2005, p. 127). Healthcare services are discussed through the lenses of change and transformation, external and internal pressure for change, and existing approaches for developing such services. This research does not focus on the different theories of change and transformation but, rather, sees these as fields where service design is used and an area where behavior is influenced in one way or another. The four academic articles are the fundamental basis of my research. Next, I will briefly introduce them. Sub-study I of this research investigated the role of service design tools and collaborative practices in supporting and developing service journeys and the hospital management practice. The article “Service Designing a New Hospital for Lapland Hospital District” (Miettinen & Alhonsuo, 2019) was published in the book Service Design and Service Thinking in Healthcare and Hospital Management: Theory, Concepts, Practice, which targets hospital managers, process managers, service designers, organizational policymakers, leaders, and researchers. The chapter of this Springer book has a very practical slant. It introduces two case studies: (1) Benchmarking healthcare in Silicon Valley and (2) Rehabilitation processes of children living in Lapland. The case studies reveal two significant areas: benchmarking and visual design methods. Benchmarking is a fast, cost-effective approach used to understand the best practices and presents evidence of different management practices based on lean, agile, and human-centered approaches and the quality, effectiveness, and timely availability of services. Visualized design methods and concretization tools support the communication and perception of a multi-layered, complex organization. In addition, workshops where the visualized data are represented and discussed are a crucial starting point in meso-level development, where actors from public and private hospitals, patients’ associations, or information technology (IT) vendors collaborate at the organizational, regional, and local levels (Beirao et al., 2017). The second article, “Designing New Hospitals – Who Cares about the Patients?” (Alhonsuo & Colley, 2019), is a short paper that was Alhonsuo: Early Phase of Healthcare-Related Service Design 22 23 presented as a poster. It describes sub-study II of this research, which investigated patients’ experiences in the pre-construction phase of new hospital and healthcare service design. Although this research did not address the role of patients in the early development, I became interested in new hospital design and construction projects, especially in how experts in this context understand, for example, the values of co-design with patients and their participation in the construction projects. Even though previous studies stressed the potential benefits of patient-centered co-design (e.g., Donetto et al., 2015), the results of case study 2 of this sub-study showed the diversity of opinions and challenges regarding patient involvement in these kinds of hospital construction projects. The sub-study emphasized that challenges, such as limited timescales and resources, were faced in the use of co-designing and patient-centered methods. We found that a good practice for concretizing healthcare-related services in the construction phase, where many ideas are still quite abstract, is virtual reality (VR) and physical replicas of, for example, treatment rooms. This article creates an understanding of how differently design methods are utilized in such a massive, complex, and expensive development project as the construction of a new hospital. The third and fourth articles focus on healthcare-related design sprints. As mentioned previously, change and transformation are topics covered by this research, and thus, design sprints were investigated as good opportunities to advance cultural shifts in organizations (Kutvonen, 2017). I had an opportunity to investigate healthcare-related design sprints even further, which was ultimately a crucial part of the outcomes of the research. The third article (sub-study III), “Healthcare Design Sprints: What Can Be Changed and Achieved in Five Days?” (Alhonsuo, Hookway, Sarantou, Miettinen, & Motus, 2020) presents an overview of the strengths and weaknesses of healthcare-related design sprints. I discuss the challenges for change in design sprints and how the synergy among participants was created through an agile way of doing. The final article (sub-study IV), “Participation of Healthcare Representatives in Health-related Design Sprints” (Alhonsuo, Sarantou, Hookway, Miettinen, & Motus, 2020) zooms in on a very practical level of the design sprints and observes the roles of healthcare professionals from the viewpoint of how they can support design sprints in the development of healthcare-related services. This academic research is written with a very practical emphasis and aims to reach people working with design in the healthcare field, such as healthcare practitioners, academics, and students. It does not provide Alhonsuo: Early Phase of Healthcare-Related Service Design 24 ready-made answers or truths but, rather, constructs my learning as an inspiration to tackle the early phase of the development process. Even though the focus is strongly linked to healthcare service design, the outcomes can be scaled across other organizations. I hope you enjoy the journey and where this research will take you. 1.2. My Research Journey During my journey as a researcher, I have had opportunities to work with multi-disciplinary teams and get to know people with different research interests, backgrounds, and experiences. I have heard of and seen many inspiring academic journeys. These stories have helped me find my own research interest and have opened doors in the healthcare field—not only in Finland but also abroad. In 2014, after completing my health-related master’s thesis in service design, I knew I wanted to dig deeper into the healthcare field, not knowing how overwhelmed I would be by the number of important and urgent challenges . A typical tendency for service designers is to observe services around you—especially the ones in which you are very interested. This happens to me, too. I passionately observe healthcare services, with which I and people close to me come in contact. I conducted unofficial empirical research, for example, in an emergency polyclinic in Cape Town, South Africa, after I had badly injured my hamstring; in a small clinic in Vancouver, Canada, when I had high fever; and also, in my hometown of Rovaniemi when I had terrible stomach pain. I observed the healthcare my dear grandfather received in his last years. Observation has been surprisingly successful, but it has included many sad stories from people around me. People have been willing to share their experiences with me because of my research interest, knowing that due to ethical considerations, I must keep their stories inside me and not make them part of my research. Those stories have pushed me to continue my research and have reminded me many times why I am doing this. They have given me motivation to continue even though the road has been rocky. Here, I would like to express my heartfelt gratitude to those anonymous people. The complex healthcare PhD journey was not straightforward. I was overwhelmed with the numerous interesting areas and caring processes to consider. I wanted to start with palliative care and end-of-life experiences, but I realized quite soon that I was not ready to jump into that dark water. I replanned my research and decided to study hospital construction projects Alhonsuo: Early Phase of Healthcare-Related Service Design 30 31 presents the main findings and outcomes from the four sub-studies, which are contained in their own respective subsections. At the end of Section 4, I summarize the key findings using tables. Section 5. Discussion presents the main empirical findings and describes them in terms of the theoretical framework. Here, the practical framework is presented. Finally, Section 6. Conclusion wraps up the dissertation by discussing its impact and offers suggestions for future research. Alhonsuo: Early Phase of Healthcare-Related Service Design Picture: Maileena Tuokko Alhonsuo: Early Phase of Healthcare-Related Service Design 33 The following subsections define the theoretical background of the research, which comprises service design, co-design, and healthcare services. First, the service design subsection introduces a brief history of the service design approach, its different processes in design and development, and the most commonly used design methods when interplaying between different service levels. Second, the co-design field is discussed concerning its connection to service design and healthcare. Third, healthcare services are examined from the perspectives of organizational change and healthcare development. 2.1. Service Design The difference between products and services is more than semantic. Products are tangible objects that exist in both time and space; services consist solely of acts or process(es), and exist in time only. The basic distinction between “things” and “processes” is the starting point for a focused investigation of services. Services are rendered; products are possessed. Services cannot be possessed; they can only be experienced, created or participated in. (Shostack, 1982, p. 49) These words opened Shostack’s (1982) article “How to Design a Service.” Service design as a design discipline has taken a huge step over the last two decades, since academia and the public and private sectors around the world realized that services dominate economic growth (Bitner, Ostrom, 2. Theoretical Background Alhonsuo: Early Phase of Healthcare-Related Service Design 34 & Morgan, 2008). Besides service design, the disciplines of marketing, management, and engineering have had great input into the growing service sector (Meroni & Sangiorgi, 2011). According to Edvardsson, Gustafsson, and Roos (2005) and Mager (2004), the role of service design should be seen more as a complementary field in service development, management, and marketing. Service design aims to systematically apply design methods and principles to the design of services, and it “integrates the possibilities and means to perform a service with the desired qualities, within the economic and strategic intent of an organization” (Holmlid & Evenson, 2008, p. 341). Service design is a human-centered, collaborative, and creative approach (Blomkvist, Holmlid, & Segelström, 2010; Meroni & Sangiorgi, 2011) and is also considered a way of thinking as a part of practices for service innovations (Stickdorn & Schneider, 2011). Recently, service design has been proposed as a multidisciplinary practice in service innovation (Ostrom et al., 2015; Wetter-Edman et al., 2014), which uses “‘designerly’ ways of changing and innovating” (Sangiorgi & Junginger, 2015, p. 166). The definition of service design has not always been straightforward. Over the years, there have been discussions, for instance, on different ways of approaching service design and the role of service from various disciplinary perspectives (e.g., Bitner, Booms, & Tetreault, 1990; Clatworthy, 2010; Mager, 2008; Morelli, Götzen, & Simeone, 2021), and how the work of service design is understood (Kimbell, 2011a). As an example, Kimbell (2011a) divided service design into two main tensions, where the first tension focuses on “understanding design either as problemsolving that aims to realize what has already been conceived of, or as an exploratory enquiry involving constructing understanding about what is being designed, involving end users and others in creating meaning,” and the second considers “a tension between the view that the distinction between goods and services matters significantly, or that service is better understood as a fundamental activity with multiple actors within a value constellation” (p. 45). Another widely referred to perspective comes from Vargo and Lusch (2004, 2008), who argued that there are two different dominant logics: a goods-dominant logic (G-D logic) and a service-dominant logic (S-D logic). Briefly, G-D logic can be seen “as a category of market offerings” (Edvardsson et al., 2005, p. 118); in other words, it is a view of products. Here, the purpose of economic activities is to distribute goods that can be sold and where users are passive in the process. In S-D logic, in contrast, services are the primary unit of exchange where users and Alhonsuo: Early Phase of Healthcare-Related Service Design 34 35 customers are actively part of the services (Morelli et al., 2021; Vargo & Lusch, 2004), and thus, “value creation is best understood from the lens of the customer based on value in use” (Edvardsson et al., 2005, p. 107). Thus, services can be understood as a dynamic process where value is co-created (Vargo & Lusch, 2004). S-D logic was first introduced by Vargo and Lusch (2004, 2008) in the early 2000s, when the roles of services and goods were analyzed and identified. S-D logic identifies service ecosystems as the “unit” of analysis for value co-creation (Vargo & Lusch, 2017). The concept of a service ecosystem offers a framework for research focused on, for example, resource integration as an important means of connecting people and technology within and among service systems (Vargo & Akaka, 2012), or as Vargo and Lusch (2014) described it, the service ecosystem is a “relatively selfcontained, self-adjusting system of resource-integrating actors connected by shared institutional arrangements and mutual value creation through service exchange” (p. 24). The ecosystem framework can provide crucial insights when innovating services systematically and describing healthcare environments more accurately (Miettinen & Alhonsuo, 2019). Here, we must understand that healthcare is not only a multi-layered process in a hospital context but also part of a bigger picture as a component of the social welfare and public service structure. A complex ecosystem in its entirety including contexts and actors is impossible to design (Polaine, Løvlie, & Reason, 2013), and the term ecosystem needs to be viewed critically, as it may be misleading. Mercan and Göktas (2011) criticized the popularized term “ecosystem,” whose origin is in biology and refers to a holistic natural and sustainable system, which is what healthcare may be striving toward. My research follows Beirao et al.’s (2017) three levels of the service ecosystem: the micro, meso, and macro levels. In this dissertation, I will utilize and describe these levels and mirror them in the healthcare context to better understand the scales of development. Here, the micro level includes patient–doctor interactions or situations within the hospital where touchpoints have an important role in the internal processes. Touchpoints are tangible or intangible interactions or contact points between the end user and the service provider (Stickdorn & Schneider, 2011). As a level, it is usually the simplest to design and work with because the important stakeholders are easily reachable. The meso level focuses on hospital and other healthcare organization interactions and, thus, reaches the regional and local levels. This can be collaborations between public and private hospitals, patient associations, and IT vendors. This level already requires more preparation compared to Alhonsuo: Early Phase of Healthcare-Related Service Design Macro level incorporates the national level with actors such as government and Ministry of Health Micro level situations within the hospital e.g. patient-doctor interaction, also touchpoints ?? InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo Meso level an organizational, regional, and local level, where actors from e.g. public and private hospitals, patients associations, or IT vendors are collaborating InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo InfoInfoInfoInfoInfoInfo 36 the micro level that takes into account the possibilities and needs of other and different hospitals for both smooth collaboration and a commitment to developing their operations. The highest and most complex level is the macro level that considers government and other organizations’ actions and, thus, also describes well the definition of wicked problems, as it involves political decision-making. This three-level model has similarities with the service definitions of Morelli, Götzen, and Simeone (2021) identifying services as (1) interactions between unbalanced roles (e.g., patient and doctor); (2) an infrastructure that supports the interactions or other service activities; and (3) a systemic institution that organizes the service activities and processes (pp. 11–12). These three areas are extremely important in service design, and they all aim to create value through the different levels. The levels define different possible contexts for design and can be seen as an ecosystem that is related to the production of value. Figure 2 visualizes the three levels of a service ecosystem in the healthcare field, which is also considered later in this dissertation. Figure 2. An overview of the micro, meso, and macro levels in healthcare. (Author’s illustration) Value is co-created at these levels; however, from my experience, they require a slightly different approach and understanding from the other Alhonsuo: Early Phase of Healthcare-Related Service Design 36 37 2.1.1. Role of the Service Designer The service designer’s role is no longer one of an expert who designs and delivers solutions but of a facilitator who guides stakeholders through the co-design process (Yu & Sangiorgi, 2017). Service designers “collect, listen to, and synthesize different perspectives to support the non-designers’ creative efforts and guide the different inputs toward a valuable solution” (Malmberg et al., 2019, p. 9). They give people a space where they have permission and the power to influence a design process, and through cyclic co-design work, different design methods can be developed further to allow participation, engagement, and creativity (Miettinen, 2013). Design thinking is an integral part of service design as well as the service designer’s mindset. According to Miettinen, Rontti, Kuure, and Lindström (2012), the common characteristics of good design thinkers are empathy, integrative thinking, optimism, experimentalism, and collaboration. Design thinking should not be seen only as a mindset of service designers. The service designers must seek to transfer this mindset to other stakeholders and participants as well, because “Holistic service design is based on an interrelated and systematic approach starting with design thinking having user-driven design in its track” (Pfannstiel & Rasche, 2019, p. vi). Design thinking leads stakeholders in design teams through a systematic approach toward service innovation (Vetterli & Scherrer, 2019), and in the bigger picture, organizations must understand (service) design thinking to be able to redesign services in innovative ways (Clack & Ellison, 2019). Hence, service designers should consider the importance of design thinking at a very early stage in the design process. The fields where service designers act are wide. For instance, they can work as in-house designers or consultants in private small and medium-sized enterprises (SMEs), large public organizations and industries, or associations or societies (clubs). The healthcare field, on which this research focuses, can also be referred to as having wicked problems (see, e.g., Buchanan, 1992; Rittel & Webber, 1973; Suoheimo, 2020), which means that these problems are highly “complex, intertwined parties involved in the development process. From this point of view, it is important to clarify one’s own understanding of what can be designed, how, and with whom. It is especially important in fields where service design is not well known. This issue also overlaps with other areas of my research and will be addressed in the discussion. Alhonsuo: Early Phase of Healthcare-Related Service Design 38 with many other problems, and probably not ‘solvable’ in the way we are used to thinking about solving problems” (Polaine et al., 2013, p. 186). In these complex contexts, service designers are engaged in situations where special skills are required, for instance, identifying the emotional skills of participants in workshops and co-creative practices (Soto, 2021). Synergy is also needed among participants and other involved stakeholders, and it can be created through design methods and design thinking. Here, as was determined in article 4 (sub-study IV) by Alhonsuo, Hookway, et al. (2020), the service designer’s role is to boost the synergy within a team. A typical way for a service designer to work is as an external consultant (Almqvist, 2019). Thus, service designers are often involved in the early phase of the development process; however, this has been criticized in many recent studies. The criticism highlights, for example, that the designer’s job is to focus on identifying user insights and idea generation and then leave the development projects with user insight knowledge in their hands (Almqvist, 2017, 2020). This is called “user insight drift” (Almqvist, 2017, p. S2524), when the user’s needs and service experiences are no longer linked and, thus, cannot have an impact on the final service solution and its implementation. The designer here is an important link between both the end users and the organization, for example. It does not matter if the designer is a consultant or a permanent player in the organization, but the deep and detailed information gathered by the service designer should not, in my opinion, be lost. It is important to emphasize the role of service designer throughout the development process and make this clear right at the beginning of the process. Service designers can have an impact on peer-to-peer learning through collaborative work (Kuure & Miettinen, 2013) and the learning process of participants, which can support, for example, changes in codesign processes and services (Kuure et al., 2014). According to Sangiorgi (2011), the evolving field of service design is moving toward a form of design for transformation, where the service design is not only changing the service itself but also changing the capacity inside the organizations and communities to steer changes themselves. Service design is explored as a catalyst for organizational change and transformation (Junginger, 2015; Yu & Sangiorgi, 2018), but it requires stakeholders’ participation in the service design process to impact and change behavior (Wetter-Edman, Vink, & Blomkvist, 2018). From this perspective, service designers are becoming increasingly needed in various areas of our social and economic systems, and thus, their capabilities should be explained in detail (Morelli et al., 2021). Alhonsuo: Early Phase of Healthcare-Related Service Design 38 39 In the literature aiming for change in healthcare organizations, we often encounter terms and theories related to, for instance, transformative change and transformational change (e.g., Sangiorgi, 2011), change management (e.g., Lin, Hughes, Katica, Dining-Zuber, & Plsek, 2011), organizational change (Julier, 2006), and institutional change (Scott, Ruef, Mendel, & Caronna, 2000). In this dissertation, I mainly refer to change and transformation as mentioned in the context and literature. Medina (2018) distinguished between the two terms as follows: change is, for example, Moving people from one department to another, adding or removing a layer in the hierarchy, assigning new managers, creating or renaming roles, recruiting some new people, or slimming down the organization, is about change. The essence is still the same, nothing new has been created from the original components. (para. 9) Transformation in an organization is “changing the essence, about creating something new based on the old parts; it is about utilizing the potential and capabilities in a different way” (para. 10). Related to transformation, the literature has introduced transformative change and transformational change. As I also use these terms several times in this dissertation, I feel it important to clarify their meanings. Transformative change is a practical and strategic process that triggers transformation and effects change within an organization and, thus, can be seen as a broad-based change. Transformational change “alter[s] what we do, not just how we do what we do” (Moss, 2017, para. 6). It leads to transformation and reshapes processes and strategies and, thus, can shift the culture in an organization. With the latter term, the focus is more on the present and what is happening at the moment. This research does not focus on the different theories of change and transformation but, rather, sees these approaches as an important part of service development and different levels of service ecosystems. Furthermore, when a service design consultant enters into a development project, they might not yet have any idea about what level of change or transformation relates to the development. This knowledge is important to understand and discuss at the early stage of the development process to ensure that the desired outcomes of the project can be achieved. In addition, I see it as important to examine change and/or transformation at the micro, meso, and macro levels, where organizational structures can be better perceived. In this research, I consider the macro level in terms of the transformative change, the meso level in between transformative Alhonsuo: Early Phase of Healthcare-Related Service Design 40 and transformational change, and the micro level as zooming in on the transformational change. 2.1.2. Different Processes in Design and Development The design landscape today is characterized by conflict and confusion, evident in a growing realization that anticipation of the needs and dreams of people is necessary but at the same time very difficult to do. We see turf battles between designers and researchers as designers try to conduct their own research and researchers struggle to do work relevant to design. With more and more disciplines becoming involved in the front end of the process, there is discontent between disciplines at multiple borders. (Sanders, 2010, pp. 117–118) Here, more than 10 years ago, Sanders described the design landscape and the role of designers and researchers in the early phase of the design process, where people from different disciplines express their own will. The world has not changed much, and these struggles and conflicts still exist. In this subsection, I will discuss this topic further from the design process perspective. The design field is full of different modifications of development processes. This is because, over the years, design research has emphasized the process of design, which has proven to be a powerful tool when developing design education and practice (Dorst, 2008). Currently, the design discipline is seen as a way for designers to create innovative solutions to complex problems by thinking and structuring the design process (Miettinen & Sarantou, 2019). The design process can be described as “the specific series of events, actions or methods by which a procedure or set of procedures are followed, in order to achieve an intended purpose, goal or outcome” (Best, 2015, p. 208). Although design processes are often visualized as a linear structure with clear phases, in the real world, they are more non-linear and iterative, including the many different needs of end users and customers. For this reason, design processes are difficult to standardize (Best, 2015). We can see the roots of the service design process in the new product development (NPD) process of the 1980s, when the need for a more systematic and linear product-related development process was recognized (Booz, Allen & Hamilton, 1982; Cooper & Kleindschmidt, Alhonsuo: Early Phase of Healthcare-Related Service Design 46 47 activities itself, which is emphasized as a very important finding in substudies III (Alhonsuo, Hookway, et al., 2020) and IV (Alhonsuo, Sarantou, et al., 2020) of this research. Design sprints The design sprint approach is an intensive, typically five-day-long design process including the elements of agile, design thinking, and lean start-up (Knapp, Zeratsky, & Kowitz, 2016). The idea for the design sprint approach emerged in 2009 when Jake Knapp (2016) was working at Google and wanted to improve team processes. This approach is usually applied by a small team and “serves to maximize the chances of making something people want” (Banfield, Lombardo, & Wax, 2016, p. 5). It is primarily used in start-up environments where digital, software, and product innovation are under development. The design sprint framework helps sprint teams answer critical business questions through rapid prototyping and user testing. Through a rigid and facilitated process and elements of agile, lean, and design thinking, teams produce a minimum viable product (MVP) or service (MVS) as an outcome of the sprint (Magistretti, Trabucchi, Dell’Era, & Buganza, 2019). The design sprint process by Knapp et al. (2016) is visualized in Figure 6. Figure 6. The design sprint process. (Adapted from Knapp, Zeratsky, and Kowitz, 2016; Author’s illustration) A design sprint is an intensive way of working, and it has similarities with hackathons, where team members collaborate intensively and work ad hoc Alhonsuo: Early Phase of Healthcare-Related Service Design 48 on a design project (Madson, 2021). Sprints are good opportunities to learn new customer-centered ways of working and, thus, advance cultural shifts in organizations (Kutvonen, 2017). The design sprint brings stakeholders together, but as Knapp et al. (2016) clarified, individuals who work alone generate better ideas than when brainstorming out loud in groups. Knapp et al. noted that “working alone offers time to do research, find inspiration, and think about the problem. And the pressure of responsibility that comes from working alone often spurs us to our best work” (p. 107). However, each of us may recognize a situation where intense work constantly revolves in the mind and ideas are processed when the workday is over. For this reason, it is important to offer tools for participants to help them take advantage of their thoughts. However, the role of the design sprint facilitator is to guide and manage from a methodological perspective and not influence the decision-making process (Knapp et al., 2016). A small amount of research has been conducted on design sprints in the social and healthcare field (Valentine, Kroll, Bruce, Lim, & Mountain, 2017; Vechakul, Shrimali, & Sandhu, 2015), although design sprints can be seen as a great way to involve and engage a busy healthcare staff on a tight schedule. As highlighted in article 3 in this research by Alhonsuo, Hookway, et al. (2020), a design sprint process does not aim for either polished or finished outcomes or service concepts that are ready to implement. The ideas are relatively weak and not structured to perfectly fit in complex healthcare ecosystems. One challenge in implementing service concepts in the healthcare field is that the service solutions fail because their implementation is perceived as unstable or unfocused (Fry, 2019; Nilsen et al., 2016). In addition, staff management is needed when new service changes must be adopted in the work routines in a hospital (e.g., Nilsen et al., 2016; Stickdorn & Schneider, 2011). From this point of view, there is not enough time during the design sprint to tackle the abovementioned challenges, but the produced ideas and the design sprint process with its creative methods can be a starting point for affecting change in organizations. In addition, I cannot help but think of the role of design sprint from the perspective of agile development, rapid prototyping, and quick user tests, which enable failing fast and often. This was also emphasized in a study by Valentine et al. (2017) and can definitely be seen as a value in health-related service design approaches, which offer different tools and methods for rapid concretization. However, at this point, I want to highlight the value of learning through design sprints, which is seen as a key finding of the articles of this research by Alhonsuo, Hookway, et al. Alhonsuo: Early Phase of Healthcare-Related Service Design 48 49 (2020) and Alhonsuo, Sarantou, et al. (2020). Learning is considered the learning of design thinking and design methods in these articles. 2.1.3. Interplay between Different Service Levels In this subsection, I will introduce different design methods that have played a significant role in this research. I will keep the main focus on visualization and concretization methods, as they had a major impact on the research overall. I will also discuss the values of design methods in perceiving different service levels and the interplay between them. First, I will provide a little background of design methods. Different design methods have had a significant role in the design field since the late 1950s (Bayazit, 2004), and the interest in them has spread beyond the design field as the attention to design thinking has increased (Kimbell, 2011b). The general method that service design uses is ethnographic research (e.g., Segelström & Holmlid, 2015), which aims to gather a holistic picture of the researched topic, engage the relevant stakeholders, and understand their experiences by interviewing and observing them (Creswell, 2014). Service design uses various visualization and concretization tools and methods (Koh, Slingsby, Dykes, & Kam, 2011; Shneiderman, Plaisant, & Hesse, 2013), which aim, for instance, to visualize and understand user experiences (Prendiville, Gwilt, & Mitchell, 2017; Segelström, 2013) or step into another person’s shoes through prototyping (Blomkvist, 2016) and role-playing (Kaario, Vaajakallio, Lehtinen, Kantola, & Kuikkaniemi, 2009). In service design, visualization is used throughout the design process. In the discovery phase, for instance, questionnaires, interviews, research diaries, and design probes can be visualized to make the materials more user friendly and creative for stakeholders to fill out. In the define phase, the data from the field are analyzed in a more understandable way and, here, the visualization usually plays an important role. This phase utilizes, for instance, different personas and mapping tools, aiming to make sense of the data and define the insights and real challenges. The mappings and modellings are very common design methods for service designers (Patrício, Fisk, Falcão e Cunha, & Constantine, 2011), such as user journey mappings, stakeholder mappings, structured service blueprints (Bitner et al., 2008; Patrício, Fisk, & Falcão e Cunha, 2008), and service walkthroughs (Blomkvist & Bode, 2012). Figure 7 presents a few examples of visualization methods. Alhonsuo: Early Phase of Healthcare-Related Service Design 50 Figure 7. Different visualization methods in practice. Top left: storyboard (Picture: Maileena Tuokko); top right: patient service journey (Picture: Mira Alhonsuo); bottom left: defined user insights on a poster (Picture: Maileena Tuokko); bottom right: desktop walkthrough (Picture: Maileena Tuokko) In the development phase of the design process, which is a phase of developing potential solutions (Design Council, 2015), the more concrete design methods are introduced, such as prototyping methods. Service prototyping is a “goal-oriented but playful way” (Schulz, Geithner, Woelfel, & Krzywinski, 2015, p. 323) to build and test different service ideas. Tangible and concrete communication tools effectively support co-design processes in communication topics, which might be difficult to articulate otherwise (Rygh & Clatworthy, 2019). Prototyping also has value because it benefits the design process by saving resources, such as time and money (Blomkvist, 2014), and thus, it is a valuable method to implement, for instance, in new hospital construction projects, where the time pressure is tight, especially at the beginning, as stressed in sub-study II of this research by Alhonsuo and Colley (2019). Prototyping has similarities with simulation, which is not a new method in healthcare (Poikela, 2017). Thus, prototyping can provide new features to support simulation. Further, service prototyping is a tool for learning about and implementing Alhonsuo: Early Phase of Healthcare-Related Service Design 50 51 transformative changes (Kuure, Miettinen, & Alhonsuo, 2014), and thus, its impact on the development of healthcare services can be significant. In this study, service prototyping was carried out in case study 2 of sub-study I and in the design sprints organized in sub-studies III and IV. It was only utilized in very rapid user testing, but was nevertheless seen as important, for example, as part of the benchmarking process. Figure 8 below shows some prototyping pictures from the design sprints. The final phase is usually for delivering the services that work (Design Council, 2015) and implementing them in the more strategic phase, where the visualizations are finalized to explain and interpret a service concept in more detail. Figure 8. Service prototyping and role-playing. On the left: role-play action – me as a nurse. On the right: design sprint teams preparing a user test for their service concept. (Pictures: Maileena Tuokko) According to Hakio and Mattelmäki (2011) exploratory, participatory, and visual design methods fit well to enhance the cross-functional collaboration in public organizations, where public healthcare belongs. The value of visualization methods is that they clarify the complex services and different service levels. Stepping into the shoes of another allows for a more detailed look at the service. There are hundreds of design methods for scaling services, and especially in multi-layer services, such as healthcare services, we need to zoom in and zoom out to obtain an overall picture of the different details, moments, and processes in a timeline. As Polaine (2013) described, the practice of service design is a continual process where we zoom in and out to see the details to achieve an overview. In service design terminology, we use the terms user journey, service moment, and touchpoints. These three areas help us to scale through the multi-layered services. The service journey (also known as user journey, customer journey, Alhonsuo: Early Phase of Healthcare-Related Service Design 52 and patient’s journey) visualizes the process of service in a timeline. The service journey is divided into service moments, which help to specify different needs and challenges in each phase. These moments consist of multiple touchpoints, which are crucial elements required to provide successful service. The service journey can be seen as a narrative, which tells a story of one’s experiences, and touchpoints are tangible or intangible interaction or contact points between the end user and the service provider (Stickdorn & Schneider, 2011). Through touchpoints, we can investigate, for example, how a referral is guiding a patient through the preparation of their care plan, how clear the information sign is at the entrance, or how music affects their feelings while waiting for their doctor’s appointment in a hallway. The touchpoint can be a flyer a caregiver hands out to a patient about their illness or a notification message reminding them about an upcoming appointment. These different touchpoints are a crucial part of the holistic process. Interplay between different service levels is important for several reasons. First, visualized service journey mapping helps to perceive a holistic picture of a specific healthcare-related service. Journey maps “can show many of the overarching values and the tone of voice of a service using a partial view” (Stickdorn et al. 2018, p. 51). In healthcare-related service development, this is important when the scale of a patient’s journey can range from a quick (a few minutes) laboratory visit to years of struggle with cancer or a lifelong disease, such as diabetes. The service journey is an eye-opening method to see different nuances and insights in a service, and it is a good tool to start the discussion. From another point of view, service journey mapping can offer the first view of the healthcare ecosystem and insights not only from the patients’ point of view but also from that of healthcare professionals. As an example, through the service journey, we might see that patients do not find the way to the right ward at the hospital, and thus, it takes them extra time to navigate and ask staff for help. After this finding, we can jump into the second step, zooming into the service moments, and observe why this navigation is difficult and where the misguidance happens. We might see that information is lacking in some of the service moments. We can then ideate and test different service solutions in these moments and see how they work in real life. The last important viewpoint, which concerns why scaling healthcare is important in this research, is to see how touchpoints can support holistic service. Here, for instance, the patient has received a paper with a detailed description of where to go next or an application navigates them inside the hospital. Alhonsuo: Early Phase of Healthcare-Related Service Design 52 53 The abovementioned elements build the puzzles together, forming the picture of internal and external ecosystems. Service journey mapping can be one way to understand patient journey approaches, which Simonse, Albayrak, and Starre (2019) noted is lacking documentation in the literature. Thus, my research focuses on the very early phase of the development process and discusses, for instance, with whom and how the very early phase of service design practices should be done so that effective collaboration and understanding among different stakeholders can be sought, and thus, a design-driven process with its functions can be learned, embraced, and accepted in healthcare-related service development. 2.2. Co-design In my research, I followed the co-design approach, which shares similar fundamentals with co-creation, and thus, they are often considered to be the same. Sander and Stappers (2008) referred to co-creation as “any act of collective creativity, i.e. creativity that is shared by two or more people” and co-design as a “collective creativity as it is applied across the whole span of a design process” and “to the creativity of designers and people not trained in design working together in the design development process” (p. 6). Co-design gives a voice to people who have not been part of collaborative work before in the belief that everybody is creative in the right environment. It requires creative initiative from teams, which include researchers, designers, and other important stakeholders, who are “experts of their experiences” (Sleeswijk Visser et al., 2005, p. 127). Co-design has been found to be effective in the exploration of users’ knowledge (Steen, Manschot, & De Konig, 2011; Trischler & Charles, 2019). For the abovementioned characteristics, I chose co-design as a fundamental approach for my research along with service design, and thus, I will also discuss learning of design practices and processes as one of the key elements in my research. At this point, let us take an initial look at the roots of co-design. The value of involving both end users and other stakeholders as part of the design process has increased since the 1970s (Sanders & Stappers, 2008), and it has become increasingly popular in businesses and organizations (Binder, Brandt, & Gregory, 2008). The role of user involvement has changed over the past few decades from design for users to design with and by users (Sanders & Stappers, 2008). The roles can vary from passive engagement to proactive engagement, where users “contribute to solving Alhonsuo: Early Phase of Healthcare-Related Service Design 54 and framing design challenges” (Keinonen, 2009, p. 145). Co-design is connected to the field of participation (Lee, 2008) with creative cooperation across the whole design process (Steen et al., 2011). Co-design happens usually in workshops, where people interact among each other through design methods. Workshops are designed so that they have an impact on people by shaping the behavior of participants (Vogt, 2009). Co-design and service design have many mutually supportive elements. According to Steen et al. (2011), two different perspectives are needed when combining service design and co-design: understanding a service’s demand side, which includes users’ and customers’ needs, and understanding the supply side, which consists of technologies and service processes. The authors also noted that it is important to first identify the goals of the development project and a few co-design activities and then associate and align benefits to these goals. Communication and interactions are not only the fundamentals of co-design but are also a central part of every service (Kuure et al., 2014). Understanding people’s behaviors and experiences and the role of technologies and touchpoints in holistic service processes is important when participants in co-design sessions represent their own fields and backgrounds (Alhonsuo, Hookway, et al., 2020). All of us can bring value to the co-design process by having practical, local, and rich experiences of services (Kuure, 2020), but this is especially true of those who have first-hand knowledge and lived experience of the service. Here, empathic design is centered within service design studies, requiring designers to focus more on these real-life stories (e.g., Mattelmäki, Vaajakallio, & Koskinen, 2014) and supporting a creative understanding (Postma, Zwartkruis-Pelgrim, Daemen, & Du, 2012). According to Mattelmäki and Battarbee (2002), “Design empathy is needed when going from rational and practical issues to personal experiences and private context” (p. 266). This is important in the context of healthcare, where people tackle very sensitive, personal, and private issues, and it should also be considered in the early phase of service design and codesign processes to ensure quality and trust in cooperation. Thus, I also emphasize the trust between the participants, which was also considered in the sub-studies of this study (Figure 9). Alhonsuo: Early Phase of Healthcare-Related Service Design 54 55 Figure 9. Building trust between participants and creating team posters in design sprints (sub-studies III and IV). (Pictures: Maileena Tuokko) Co-design is widely used in the healthcare domain to understand the field in terms of its bigger picture (e.g., Pirinen, 2016; Trischler, Dietrich, & Rundle-Thiele, 2019; Vaajakallio, Lee, Kronqvist, & Mattelmäki, 2013) but also when developing specific treatment processes (e.g., Kronqvist, Järvinen, & Leinonen, 2013; Pyatt, Sinclair, & Bibb, 2019). In many healthcare-related studies, experience-based co-design (EBCD), originally called experience-based design (EBD), is integral to co-design and service design, which means that patients and healthcare staff’s experiences are closely considered (e.g., Bate & Robert, 2007; Donetto, et al., 2015; Herriott, 2018; Robert et al., 2015). In this dissertation, the inclusion of patient experiences is only slightly discussed, as the research examined the involvement of healthcare professionals in the design process. The research did not underestimate the importance of patient participation but, rather, built a foundation for collaboration and understanding among healthcare professionals to make patients more involved and welcomed later in the design process. Nevertheless, challenges are highlighted and raised for discussion in co-designing healthcare fields with service design. For instance, how to deal with sensitive and less engaging cases with vulnerable user groups and how the relevant users can also actively and equally contribute in the early stages of the service design process have been explored (Trischler, Dietrich, & Rundle-Thiele, 2019). Researchers have also investigated how the co-design process following EBCD requires healthcare professionals and patients to renegotiate their roles and expectations and reform the relationships of power between citizens and public services (Donetto et al., 2015). In this regard, they have tried to determine how to select the participants for co-design workshops when self-selecting may result in Alhonsuo: Early Phase of Healthcare-Related Service Design 56 bias and the participants do not represent the desired population (Boyd, McKernon, Mullin, & Old, 2012). According to Hakio and Mattelmäki (2011), co-design in public organizations might face difficulties related to communication between design and healthcare terminologies, trust, and shared understanding within the project group. They also suggested that there might be issues such as the risk of losing credibility or fear regarding design practices. The authors stressed that it is extremely important to consider how design practitioners approach the orientation phase of co-design and design methods. PowerPoint presentations or seminars are not enough to introduce a co-design approach, and because of this, there is a need for more hands-on experience. They also discussed the importance of empathy for other people, such as colleagues, stakeholders, or users, as being able to position oneself in someone else’s situation is the key to transformation and change. Although patient involvement and patient experiences have been emphasized in many of the studies noted above, in this research, I have brought forward the need to build trust between actors in the design field (e.g., service designers, design researchers, design students) and actors in the healthcare field (e.g., doctors, nurses, other experts). The critical issues mentioned in the previous paragraph can then be discussed with participants in the early phase when the understanding of the possibilities and practices of service design and co-design is clearer. In addition, my research has found that there is a need to put effort into fostering the learning of design thinking and methods in practice, encouraging collaboration and knowledge-sharing among the healthcare practitioners, and using co-design and service design in the early phase of the design process. 2.3. Healthcare Services Healthcare is a complex field of silo-structured processes, where interactions among various stakeholders are relied upon (Bowen et al., 2013), and is a universally used service that impacts economies and quality of life (Berry & Bendapudi, 2007). Healthcare is described as a “routine part of our lives, but it is often anything but routine for the people receiving it” (Goodwin, 2020, p. 37). Nevertheless, healthcare is a critically important service, where we often end up unintentionally, not knowing how much it will cost or what will happen. It is an unknown quantity with an unknown duration Alhonsuo: Early Phase of Healthcare-Related Service Design 62 63 service design handbooks do not offer tips or templates for doing it. Benchmarking should be considered a part of a continuous improvement process (Kay, 2007), and from that point of view, it is a valuable process for service design, where services are constantly evolving and never “ready.” In healthcare, solid mainstream hospitals are continuously using benchmarking to avoid risks, defects, and limited patient safety and for improving quality (e.g., Liedtke et al., 2017; Rasche, Margaria, & Floyd, 2017). In addition, benchmarking can be used for internal purposes, where professionals collect performance data and then benchmark them with the aim of improving the internal culture and making clinically meaningful quality changes (Gleason & Bohn, 2017). Gleason and Bohn (2017) consider it a way to “change the mentality” (p. 151). Article 1 of this research by Miettinen and Alhonsuo (2019) emphasizes that change processes need peer-to-peer learning, and thus, transformational change in organizational cultures and a commitment at the management level are needed so benchmarking can ensure that the outcomes of service design processes are observable. This also requires that all stakeholders understand how the scaling-up step can take not only innovations from experiments to implementation but also strategic day-to-day management. As addressed in article 2 of this research by Alhonsuo and Colley (2019), the use of benchmarking remains perhaps one of the most costeffective and fastest approaches for a new hospital to adopt general best practices for patient-centered care. Yet benchmarking as a process seems to be lacking consideration in the service design literature. As a possible process for understanding healthcare services at the micro, meso, and macro levels, there is huge potential to develop tools for benchmarking and reflect the experienced processes in a holistic way, for example, through prototyping in role-playing or desktop walkthroughs. I will discuss this gap later in my conclusion. Alhonsuo: Early Phase of Healthcare-Related Service Design Picture: Maileena Tuokko Alhonsuo: Early Phase of Healthcare-Related Service Design 65 3. Research Design As a researcher, I have always been curious about the people around me, and the design field has provided many opportunities to work with different people. I understand the world around me better when I am part of it in a practical sense. I learn by doing, which is the reason why I have been doing my research in design and in a very practice-oriented way. This has definitely guided me on my way while constructing this dissertation. The choice of methodology for this study was defined through the objectives of four sub-studies conducted for this work. In addition, my own previous and ongoing professional experiences as a service designer have had an influence on the selected approaches. The main objective of my research is to describe how service design and co-design approaches support healthcare-related service development, especially in the early phase of the design process. The aim is to answer the research question through the four sub-studies. The first sub-study has been published as an academic book chapter and the other three have been reported in international peer-reviewed conference proceedings. This section will discuss the research design approach and its philosophical relationship to the topic. At the end of the section, I will describe each sub-study in detail, explaining the methods, data, and analyses. 3.1. Research through Design We can see design everywhere around us. All environments, furnishings, clothes, technologies, communications systems, artifacts, services, and Alhonsuo: Early Phase of Healthcare-Related Service Design 66 processes have been designed. The designer’s role is to “produce efficient, effective, imaginative and stimulating designs” that are based on the communication of a specific need or proposal (Cross, 2007, p. 33). The definition of design involves multiple interpretations and approaches. Design has been seen as instrumental to problem-solving (Simon, 1973) and plan-making (Rittel, 1987). Schön (1987) crystallized design as an action where the designer is an individual who can look at a different complex and incoherent situation, have the imagination to think about how things can be done differently, and then design something new out of it. Design problems have been seen also as “wicked problems,” which are loosely defined as problems that are difficult or impossible to solve, such as those related to healthcare, quality of life, and poverty (Rittel & Webber, 1973). Here, “designers have to learn to have the self-confidence to define, redefine and change the problem-as-given in the light of the solution that emerges from their minds and hands” (Cross, 2007, p. 24) We can see complexities, needs, varieties of design disciplines, and the increasing speed of new innovation and technologies affecting and challenging design as it is. Considerable pressure is put on designers because of their ability to design something totally new. According to Nelson and Stolterman (2012), we will never be able to ground design on the idea that the “right” design is out there, embedded in reality, just waiting to be discovered. To the contrary, design will always be about creating something that does not yet exist. It is not about finding something already in existence. (Nelson and Stolterman, 2012, p. 28) Over the last few decades, design research has put its roots down in academic and theoretical fields. There has been research on design practice to understand the processes; research for design to improve the results; and research through design, which, as the newest direction, “helps to communicate the nature of this relationship toward other academics” (Bredies, 2016, p. 12). The research through design (RtD) concept, on which this research is also based, was introduced by Frayling (1993). Later, RtD was critiqued by Zimmerman, Stolterman, and Forlizzi (2010): “We argue that there is a need for serious development of RtD into a proper research methodology that can produce relevant and rigorous theory” (p. 216). RtD falls under the rubric of constructive design research (Koskinen, Zimmerman, Bonder, Redström, & Wensveen, 2011), which also overlaps with this research. When the aim of the research is to develop a concrete Alhonsuo: Early Phase of Healthcare-Related Service Design 66 67 plan, instrument, or process model, and when it comes to creating a new kind of reality on the basis of theories, existing studies, and research data, constructive research is a suitable approach (Ojasalo, Moilanen, & Ritalahti, 2015). Design in public services, such as healthcare services addressed in this research, demands a new form of design practice, and it is essential to have a design researcher as a social expert for such work, according to Press (2016). Press also noted that “the danger of service design for public services is that it becomes incorporated within the institutional paradigm that it has the potential to challenge, and thus becomes just another technocratic tool of the public sector” (p. 25). Moreover, according to Press, a design researcher as a social expert should rather aim to construct social problems through design and be actively part of them, not aim to solve the social problems. This truly has connections within this research, as I actively participated in the sub-studies described here. By adopting service design and co-design approaches and engaging a wide range of people, we can together aim to reconstruct future directions for our societies. By adapting research through design in my own study, I strengthened the link between service design practice and design research. The practical frameworks for health-related development were, thus, created during the research. Figure 11 is adapted from the illustration by Saunders and Tosey (2012), which is the metaphor of the “Research Onion.” It provides an overview of my research design, representing the elements that need to be considered in relation to other design elements. These elements are described in detail in the following subsections. Alhonsuo: Early Phase of Healthcare-Related Service Design Paradigm Strategies Methods Data Analysis Constructivism Qualitative research Ethnographic studies Case studies Content analysis Workshops Interviews Research diaries Field notes 68 Figure 11. Overview of the study. (Author’s illustration) Alhonsuo: Early Phase of Healthcare-Related Service Design 68 69 3.2. Constructivism The worldview of this research is based on constructivism, also known as interpretivism and social constructivism. A worldview is “a general philosophical orientation about the world and the nature of research that a researcher brings to study” (Creswell, 2014, p. 6). In constructivism, a reality is socially constructed and individuals engage with their world in an attempt to understand the world in which they live and work. The researcher aims to listen to and understand people and trust the views of multiple participants through language, and then interprets the findings in a process shaped by the experience of the researcher (Creswell, 2014). In service design research, constructivism is one of the most commonly used epistemologies (Sun, 2020) and theories in practice (Yang & Gergen, 2012). Constructivism is typically characterized by an inductive approach to research, where the research starts in real-world settings and contexts and in which empirical data are gathered. Then the researchers interpret the data, leading to the development of theories and, thus, the construction of knowledge. Constructivism is closely related to learning, where learning is seen as an active process of constructing knowledge, and through this, making sense of the world (Adams, 2003). The common element of all varieties of constructivist theories is “the nature of the learning environment is one of experimentation and dialogue, where knowledge is seen within the context of problems to be discussed and solved” (Adams, 2006, p. 245). Here, the learning is a social process (Shepard, 2000), and in my research, it happened through co-design practices and workshops. According to Creswell and Creswell (2018), as a researcher, I am actively part of the research and influence the interpretation of the phenomenon through my own background and perspectives. This truly has an impact on the research process, where I can choose the topic and problem of the research and formulate the research questions and methods (Crotty, 1998). In addition, constructivism relies on a qualitative research framework, which is also used in organizational research and organizational change (Doldor, Silvester, & Atewologun, 2017). From an ontological perspective, which is defined as a consideration of being and what is and what exists (Packer & Goicoechea, 2000), constructivism has multiple perspectives and realities. “Realities” in this viewpoint were defined by Guba and Lincoln (1994): [Realities are] apprehendable in the form of multiple, intangible Alhonsuo: Early Phase of Healthcare-Related Service Design 70 mental constructions, socially and experientially based, local and specific in nature (although elements are often shared among many individuals and even across cultures), and dependent for their form and content on the individual persons or groups holding the constructions. (Guba and Lincoln, 1994, pp. 110–111) According to Bisman and Highfield (2012), reality is created by the mind. They argued that different social organizations, cultures, and experiences can create several social realities. They pointed out, however, that what is real is specific to an individual, and there might be similarities between individuals and groups of individuals in understanding what is real. 3.3. Research Strategies and Methodological Choices I used a qualitative research strategy with ethnography and case study as my methodological choices. Research of this type uses an inductive approach, where researchers start with a real-world setting and gather empirical materials from case studies. After this come the interpretation and reflections with a hypothesis and theory. Qualitative research follows an inductive design, where meaningful and descriptive data are generated (Leavy, 2017). This is in-depth research, where the aim is to collect different forms of data from different sources and investigate them from many different perspectives (Muratovski, 2015). According to Leedy and Ormorod (2010), qualitative research fits best for describing, interpreting, and verifying topics. It is ideal for understanding settings, processes, relationships, or people, which rings true with this study. In a service design setting, co-designing with people is crucial. Even though the developed topics are related to services and processes, they tie people and their relationships together and help to clarify user experiences. Service design methods and tools aim to understand user experiences and the stories behind them through open-ended, narrative, and visual ways, where participants can share their views and opinions freely. Case Studies Case study approaches were used as a research strategy in sub-studies I, III, and IV. The case study is a qualitative research framework with a set of tools for data collection regarding complex phenomena (Baxter & Jack, Alhonsuo: Early Phase of Healthcare-Related Service Design 70 71 2008), and it is linked to the constructivist paradigm (Stake, 1995). The case study approach enables multiple levels of analysis from a single study (Yin, 2009), which can be a program, activity, process, or individual(s) (Creswell, 2014). According to Yin (2014), case study as a research approach should be considered in situations when the research focus is on answering “how” and “why,” as relevant behavior cannot be manipulated by those who are involved in the study, and the study under investigation is contemporary. In an explorative way, case studies give an in-depth understanding of a real-life context, which fits well in the service design field. In general, case studies are criticized for lacking rigor and not following systematic procedures, being difficult to generalize, and taking up too much time while producing large amounts of information (Yin, 2014). It was obvious that during the case studies, the forms of data collection and procedures changed to better suit the situations and environment. Consequently, in some cases, the amount of data increased but was not too overwhelming to take into account. It should also be noted that in these case studies, the phenomenon was healthcare-related processes in the hospital context, where different stakeholders co-design using different design methods. Ethnographic Studies Previously, I introduced a case study approach that has some similarities to ethnographic studies. Ethnographic studies aim to obtain a holistic picture of the topic under investigation and engage individuals and understand their everyday experiences by interviewing and observing them (Creswell, 2014). Ethnography, which Leavy (2017) described as “a written text about culture” (p. 259), studies social interactions, people’s behavior, what they believe, and other perceptions that appear within communities, organizations, and groups (Muratovski, 2015). Both service design and ethnographic studies aim to provide holistic insights into different cultures, which Muratovski (2015) defined as “people’s views and actions” (p. 56). Also under investigation are the elements of the environment around them, including the sounds, sights, and locations, which can be linked as touchpoints, according to service design literature. Service touchpoints are tangible objects or spaces (Moritz, 2005) in the line of interaction between the customer and service provider, or they are intangible elements, such as sounds, smells, and temperature. The service touchpoints are around us in different service moments and have an overall impact on how we Alhonsuo: Early Phase of Healthcare-Related Service Design 72 experience these moments. The service touchpoints are important to recognize in ethnographic studies. Ethnography in the context of design is embedded in iterative design processes, is short-term and quick in its duration (Müller, 2021), and can offer numerous options for dealing playfully with collected data, which requires not only explication and reflection but also discipline (Müller, 2020). In design ethnography, “it is permitted to burst open conventions, explore boundaries and expand cognitive horizons. (…) Design ethnography can mean observing social situations passively in order to change them afterwards through interventions, then observing the results again, and so on” (Müller, 2020, p. 227). As in my research, the research process of design could change unexpectedly. In it, the researcher’s role is to adapt during the process and be creative, even playful, to better understand elements of the environment, for example. Nevertheless, ethnography emphasizes three key elements that researchers need to consider: type of communication, level of integration, and duration of the study (Muratovski, 2015). The first element, type of communication, is crucial in research done in the healthcare field, where my personal motivation for conducting the study alone was not enough. From my experience, there needs to be a clear introduction to what is going to happen, how it is done, and what its value is for participants. In the healthcare context, professionals from the hospital give their time for the project, and the hospital lacks resources while the professionals attend a workshop. If the communication is unclear, it is difficult to engage them. In addition, the type of communication is crucial during the study especially when experts from various healthcare professions in the hospital, patients of different ages with different backgrounds and diseases, and I as a designer meet. The second element, level of integration, refers to the researcher being either an “outsider” or “insider,” as Muratovski (2015) explained. An experienced researcher knows when to be a silent observer or interviewer and when their role should be more active and engaging. Regarding the third element, duration of the study, especially in healthcare-related co-design workshops, there needs to be enough time for thinking through complex scenarios, experiences, and service processes. This has been a huge learning point for me as a researcher, where a period of silence is not always a moment for ignorance or even for unconsciousness. It is usually a moment for in-depth thinking and processing—and sometimes, it exerts positive pressure that pushes people toward dialoguing. In the past, it was common to engage in ethnography as a long-term commitment, but that has changed, and it is currently more Alhonsuo: Early Phase of Healthcare-Related Service Design Design probe Design probe Design probe 1. workshop 2. workshop 3. workshop 78 79 the development of the hospital’s operations, and why?”; “What did the benchmarking site visits provide for the group?”; “How would you develop benchmarking work itself?”; “How did you apply lean/huddle in your own work after the trip?”; “What kind of experiences have there been?”; and “How did benchmarking open up ecosystem thinking from a service perspective?” These data were transcribed and analyzed via a qualitative content analysis method. Case Study 2: Rehabilitation Processes of Children Living in Lapland The second case study focused on examining and developing existing children’s rehabilitation processes and ecosystems in the eight municipalities of Lapland. The case study was conducted from February 2017 to June 2017 and was part of a project called Critical Communication, Safety and Human-Centered Services of the Future (CRICS). Strong collaboration was done with Lapland Central Hospital, especially with the children’s department. The hospital coordinated the case study participants because they had contacts with healthcare professionals in the municipalities. These professionals were doctors, nurses, different therapists, such as physiotherapists and speech therapists, neuropsychologists, and social workers. Participants in the case study used service design tools to visualize the existing healthcare ecosystem surrounding municipalities’ rehabilitation facilities and to tackle local challenges in this program. The aim was to develop new solutions for better and more efficient services that can provide equal healthcare to all families and their children in this remote region. The case study was conducted in three workshops and three design probes (Figure 13). Figure 13. The research process in case study 2: Rehabilitation processes of children living in Lapland. Alhonsuo: Early Phase of Healthcare-Related Service Design 80 Design probes are defined as user-centered and design-oriented selfdocumentation tools where the aim is not only to understand human phenomena and design opportunities (Mattelmäki, 2006) but also to “purposefully invite or provoke users to reflect on and verbalize their experiences, feelings and attitudes, and to visualize their actions and contexts.” (Mattelmäki, 2005, p. 83). As a method, it activates participants in a playful and creative way to collect exploratory and personal data. The probes are widely used as a design method, and according to Mattelmäki (2005), they can be presented in four different settings: cultural probes (Gaver & Dunne, 1999), informational probes (Hemmings, Crabtree, Rodden, Clarke, & Rouncefield, 2002), technology probes (Hutchinson et al., 2003), and empathy probes (Mattelmäki & Battarbee, 2002). This study utilized probes as an information gathering method instead of trying to specifically understand how people were feeling. The aim of the first probe was to collect data on existing resources, needs, and challenges. The probe was a questionnaire in pdf format with typing options. It was sent to municipal healthcare professionals with an introduction. They could fill out the questionnaire on a computer or print it out, handwrite it, and scan or send it via the post. We received 25 responses. The answers were transcribed into Excel and then into an expansive printed template, which we called the resource blueprint. The visualized resource blueprint was used in the first workshop, and it proved to be crucial throughout the whole project. It worked as an informationsharing platform and opened up the discussion between professionals. It was also crucial for explaining the service ecosystem framework of all eight municipalities. The first workshop was held in Rovaniemi with 24 participants. The aim of the workshop was to understand the resources, needs, and challenges in children’s rehabilitation processes in Lapland. Data from the questionnaires and resource blueprint were used and supplemented but not finalized. The workshop was very dialogue-focused and achieved two objectives: agreement on definitions of perceiving children’s rehabilitation in Lapland and concluding six development challenges. The latter was generated in a form of mind map in small groups. The data were documented in pictures and transcribed into Excel. The second design probe was a questionnaire with nine responses. The aims were to seek different solutions or ideas for more adaptive services in rehabilitation. Question examples from the probe concerned how to enable the active roles of the child and the family in rehabilitation (planning, implementation) and to think of ways to make (rehabilitation) Alhonsuo: Early Phase of Healthcare-Related Service Design 80 81 services easily accessible to families. We also wanted to understand the external resources, for example, in schools or hobbies and how we could utilize those in rehabilitation programs. In addition, the Lapland Central District sent questionnaires to families, who were their existing or past customers, and asked for feedback on and development ideas for their services. Thirty questionnaires were sent and 11 replies were received. The data from the design probe and questionnaire were themed and presented in the following workshop. In the second workshop, data from the previous probes and questionnaires were presented and discussed with 22 participants. The main objective of the workshop was to create a service journey that visualized six main phases: (1) worrying, (2) contacting a service provider, (3) assessing the child’s functional capacity, (4) creating a rehabilitation plan, (5) implementing the plan, and (6) controlling and assessing rehabilitation results. This visualized process supported participants in defining the entire rehabilitation process and understanding the most important needs involved. The third design probe was done with the Google Forms questionnaire tool, utilized the created service journey, and deepened the internal processes in each of the six phases. We asked professionals to highlight such aspects as who is part of the phase, where it happens, how it happens, and what kind of minimum viable service/product would be suitable in this phase. In addition, the questionnaire included ideas already created, and we asked participants to vote on the best ideas. The most voted for ideas were prototyped in the last workshop. We collected 15 replies from the online inquiry. The last workshop summarized the whole case study. The aim was to prototype and role-play the most voted-for ideas with 26 healthcare professionals. Two scenarios were selected and the participants took on different roles, such as mom, dad, child, teacher, nurse, and physiotherapist. The workshop was video recorded and iterated service scenarios were visualized as storyboards. The service design outcomes of case study 2 were three visualized service concept pictures (Figure 14), which were presented in a subsequent healthcare seminar. The first service concept was a digital platform to provide different rehabilitation services for families without a doctor’s referral. This idea would enable families to, for example, use virtual reality as a new way to motivate children with movements. The second service concept was a digital service allowing a multi-professional team to meet families quickly and easily without long journeys and scheduling Alhonsuo: Early Phase of Healthcare-Related Service Design 82 challenges. The service first would determine where the challenges are, on the basis of which the system can select the right professionals. The system would create a separate diary for the child, enabling the family and professionals to follow the rehabilitation as a service path, see past and future appointments, and compile a rehabilitation plan. The system would allow for seeing how the child has developed during the rehabilitation process. Parents could also interact with experts via chat, if needed. The third service concept, School as part of rehabilitation, was developed as a support service for teachers in schools that would enable teachers to contact a neuropsychiatric coach and ask for support and assistance during teaching. A neuropsychiatric coach would provide mental support to a child or adolescent in coping with everyday challenges using their own strengths. Thus, the integration of the teacher into rehabilitation was deemed important. Figure 14. Examples of visualized service concepts created for families and healthcare professionals during the case-study 2 in sub-study I. (Author’s illustration) 1. Service concept 3. Service concept 2. Service concept Alhonsuo: Early Phase of Healthcare-Related Service Design 82 83 3.4.2. Sub-Study II The second sub-study investigated patients’ experiences of the design process of new hospitals, especially co-design methods including patients. I was especially curious to study the pre-construction phase of new hospital design, where changes may be more easily incorporated and patient voices included. The article was a short paper that aimed to validate and extend existing discussions on the challenges, needs, and good practices of applying patient-centered co-design methods. The paper described the co-design methods in two new hospital builds through semi-structured interviews, which I organized with three experts in two hospitals. In addition, I observed a co-design workshop between hospital staff and hospital architects in one of the hospitals. The interviews and observations were done in 2018. The interview questions aimed to clarify the big picture of a new hospital design process, especially the pre-construction part. The questions consisted of four main themes: (1) planning phases of new hospital design, (2) the stakeholders who were involved and why, (3) what methods and tools were used in which phases, and (4) how patients participated in the design and decision processes. I aimed to get a deeper understanding of what works and what does not. The interviews were recorded and transcribed. I used an affinity diagramming approach to identify the main themes from the data. The co-design workshop between hospital staff and hospital architects in one of the hospitals focused on the cardiology ward. I observed the two-hour-long session, where an architect, four nurses, and two doctors discussed the floor plan of the ward. They focused, for example, on the waiting and patient areas in the ward. I mainly observed how the patients were being considered during the discussion and how the services were concretized in the waiting and patient areas. I took notes during the workshop and added the data into the affinity mapping used in interviews. 3.4.3. Sub-Studies III and IV Sub-studies III and IV were conducted through three health-related design sprints in the form of case studies. These were held in three different locations: Gothenburg, Sweden; Tallinn, Estonia; and Rovaniemi, Finland. The design sprints were part of the research project called Co-designing Alhonsuo: Early Phase of Healthcare-Related Service Design 84 Healthcare, which was a two-year joint initiative of higher education and healthcare institutions of the three abovementioned countries. The project had three main aims: to attract more designers to the healthcare sector, to encourage more healthcare providers to use “design as process” and “design as strategy,” and to develop more digital health solutions that support new organization, process, and payment models in healthcare. The project started in November 2018 and ended in December 2020. The participants who supported the project in Sweden were from the University of Gothenburg, HDK-Valand; Academy of Art and Design, Sahlgrenska School of Innovation and Entrepreneurship (SSIE); Sahlgrenska Academy School of Medicine; and Sahlgrenska University Hospital and Children’s Health Center Services. Those from Estonia were from the Estonian Academy of Arts, Connected Health Cluster, and North Estonia Medical Centre, and those from Finland were from the University of Lapland and Lapland Central Hospital. The collaboration among academics was strong during the project, and it supported and encouraged research mobilities of the students and staff. The design sprints in each location varied. The local hospital or health center gave a brief for the design sprint, and the planning and scheduling were done by the local team. The design methods used in each location were also differentiated by the number of participants, briefs, and facilities. A concise overview of the respective design sprints, data collection, and participants is discussed in the following paragraphs. Case Study 1: Design Sprint in Gothenburg, Sweden The four-day design sprint in Gothenburg was conducted in April 2019. Participants in the design sprints were 18 students with international and multidisciplinary backgrounds and four hospital representatives. Two of the hospital staff were working in Child Health Centre (BVC) Services, and two others were from the North Estonia Medical Centre. The design brief was to improve communication between nurses and parents in BVC Services. In Sweden, children participate in BVC Services from birth to the age of 6 years. There were two focus areas: information on the different visits during the child’s time at BVC, and information in regard to preparing for a visit (the child’s perspective). As an outcome of the three design sprint teams, communication tools, such as “Chatbox” and a “Yearbook,” were created to enhance the interaction between parents and professionals. The ideas were given to BVC but were not yet implemented. Alhonsuo: Early Phase of Healthcare-Related Service Design Design sprint team: 18 students 4 nurses Ideation Concept development Testing Creating videos Presentations Field research Collecting & visualising insights & data Clustering insights & data Presenting previous cases Introduction Team building Briefing Mentoring by Ethno station - interviews 9 research diaries Gothenburg, Sweden At the campus Participants: At the campus At the campus At the campus Data: Mentors: 2 nurses 1 parent Facilitators: 4 from design field Field notes Unstructured interviews 84 85 The design sprint process followed simple steps using a design process starting from an investigation and field work, mapping down the data to define the design challenges, and then continuing to the solution through ideation and prototyping. Figure 15 summarizes the design sprint process and the design methods used in Gothenburg each day. Figure 15. Design sprint process in Gothenburg, Sweden. Data from the design sprint in Gothenburg were collected through research diaries, field notes, and unstructured interviews. The research diaries were sent via email right after each design sprint day. The questions (4 varied questions per day) considered various topics, for example, “What kind of design methods were used during a design sprint day, and how did the methods work in your case?”; “Which methods helped to understand the case better?”; “What kinds of methods would have worked better to capture the needs or dreams of parents and/or children?”; “How did you think the design sprint concept would work in health-related service development?”; and “What are some other reflections, experiences, or thoughts of the day?” We received nine replies in total. The research diaries appeared to be too tiring for the design sprint participants to write in after intensive days. I took field notes during the design sprint, and I continually observed the participants, design methods used in the design sprint process, and the environment and facilities offered to the teams. I did visual and written notes from the field, where I highlighted each design method used in the design sprint process and the teams’ thoughts about the method. I also Alhonsuo: Early Phase of Healthcare-Related Service Design 86 made notes during the unstructured, ad hoc interviews when asking participants specific questions, such as how the intensive days could be done better to reach the best healthcare-related information and what the participants felt was most difficult during their most intensive days. Case Study 2: Design Sprint in Tallinn, Estonia The second design sprint was held in Tallinn in April 2019. It was a fiveday-long design sprint done in collaboration with North Estonia Medical Centre (PERH), ER/Trauma, Day Surgery, Stroke and Cerebrovascular, and Palliative Care units. The design sprint was part of the bigger service design course at the Estonia Academy of Arts (EKA) and Taltech. Local students of EKA had already started their exploratory research in February, but the actual design sprint process was implemented in April. Then 19 students from multidisciplinary fields and one from a healthcare background joined a pop-up design studio in the lobby of the North Estonia Medical Centre and challenged themselves in five teams one of the following five themes: (1) making the pre-visit process valuable; (2) leading a meaningful life after a stroke; (3) day surgery center; (4) death with dignity; and (5) emergency department (ED) patients’ stress and anxiety. The conceptual solutions were co-designed in each of the five teams, and the local students continued the development after the design sprint when their course ended in the summer. The design sprint teams first familiarized themselves with the existing data, which the local students had gathered and visualized for huge paper-based canvases during the first few months of the course. Next, the teams followed the basic structure of the design process, starting from the site visits, deepening the understanding with mentoring rounds, building rough prototypes and/or desktop walkthroughs from the ideas, and finally, testing, evaluating, and iterating the concepts before the final presentations. The design sprint in Tallinn offered an opportunity to utilize the healthcare professionals and experts as visiting mentors during their intensive work. Visiting mentors were from the hospital IT, quality management, communication, service, and clinical fields. The students could ask questions and gather information from the experts from specific fields, thus avoiding any confusion or other difficulties during the sprint. Figure 16 summarizes the design sprint process in Tallinn in more detail. Alhonsuo: Early Phase of Healthcare-Related Service Design Design sprint team: 19 students 1 nurses 15 research diaries Tallinn, Estonia Participants: Data: Mentors: 12 specialists from local hospital Facilitators: 3 from design field Field notes Unstructured interviews Team Canvas: team members and clarifying the topic Storyboard Site-visits Mentoring PresentationsMentoring Testing, evaluating and iterating Rough prototyping and roleplay through desktop walkthrough Mentoring Introducing five challenges Creating teams At the hospital At the hospital At the hospital At the hospital At the hospital 86 87 Figure 16. Design sprint process in Tallinn, Estonia. The data collected from the design sprint in Tallinn included 15 research diaries from the participants, my own field notes, and unstructured interviews. The research diary was an A5-size booklet with prompts such as “3 good thoughts from today,” “2 questions which arose for you,” “1 idea you’ll put into practice,” “3–5 keywords to illustrate your team’s process today,” and “other reflections, experiences, or thoughts which you feel are relevant to say.” The research diary with the prompts was created by the leader of the design sprint facilitators from EKA, who also worked as the main facilitators in this design sprint. The unstructured, ad hoc interviews were done in the same way as in Gothenburg. I observed the design sprint process and teamwork and asked questions, such as “How did you feel that the mentoring round supported you last time?”; “What would have worked as a better method or approach to reach the understanding in your design brief?”; and “How would you compare the pros and cons in this design sprint versus the previous one in Gothenburg?” The last question was asked of the students who had also participated in the design sprint in Gothenburg. I recorded field notes during the design sprint using an observation style very similar to the one I had used in Gothenburg. I observed the participants, design methods used in the design sprint process, and the environment and facilities offered to the teams. I did visual and written notes from the field, where I highlighted each design method used in the design sprint process and the teams’ thoughts about the method. Alhonsuo: Early Phase of Healthcare-Related Service Design Design sprint team: 6 students 4 research diaries Rovaniemi, Finland Participants: Data: Mentors: 2 nurses 2 from other fields Facilitators: 1 from local hospital 2 from design field Field notes Unstructured interviews At the hospital At the hospital At the hospital At the campus At the campus Creating videos Presentations Clustering ideas Voting Storyboard Prototyping chosen idea Testing Clustering insights & data Ideation Field research Mapping down findings Mentoring Briefing Team building Test journey 88 Case Study 3: Design Sprint in Rovaniemi, Finland The last design sprint was organized in Rovaniemi at the beginning of May 2019. It was a five-day-long process with two teams of three international students. The aim of the design sprint was to investigate and develop a care and treatment reservation center at Lapland Central Hospital. Due to the long travel distances in the Lapland area, the brief was divided into two case studies. The first team considered a patient who lived far from specialized healthcare institutions, in Utsjoki, which is 450 km from Rovaniemi, where the specialized healthcare is provided. The second team focused on a patient who lived in the Rovaniemi area, near the central hospital, but was busy with seasonal work and family life. The teams developed healthcare services, such as a LAPP LAB service bus to take healthcare services and e-health solutions into rural areas and a web-based service system to make the treatment reservation process more flexible by allowing patients to book, change, and cancel appointments. The design sprint process started with introducing the brief and doing the field work. The findings were mapped down, and understanding was deepened through mentoring (two nurses from the hospital and two other experts from the design/healthcare fields). Then the teams ideated different solutions and user-tested the selected ideas through prototyping. The final concepts were filmed as a concept video. Figure 17 provides a detailed process description. Figure 17. Design sprint process in Rovaniemi, Finland. Alhonsuo: Early Phase of Healthcare-Related Service Design 4. Results 94 95 4.1. Service Design Tools as Supporting and Developing Hospital Management Practices The large dataset from sub-study I is introduced in the following subsections. Here, I will answer the research question: How can service design tools and collaborative practices be used to support and develop customer journeys and hospital management practices? The results can be categorized into two areas. First, I will describe how benchmarking as a tool in the design process can support the development of hospital management practices, and second, I will introduce the design method as a way to create and share a vision and understand ecosystems in the healthcare context. 4.1.1. Benchmarking as a Process to Develop Hospital Management Practices Benchmarking is a widely used process in the healthcare field, and it can be seen as an iterative approach in the development of health-related services (e.g., Kay, 2007; West, 2021). It has value because it helps to avoid risks, defects, and limits to patients’ safety and can be used to improve service quality (Liedtke et al., 2017; Rasche et al., 2017). In sub-study I, the most significant effects of benchmarking were related to evidencing the development of lean management and “true north” thinking, which was the main objective of the case study 1. Evidencing is needed for decision- Alhonsuo: Early Phase of Healthcare-Related Service Design 96 making at the organizational and design levels, as it helps to drive learning and transformation forward (Foglieni et al., 2017). According to Fry (2019), evidence is important when new service processes and practices are introduced in hospitals. Sub-study I determined that through benchmarking, we can ensure the quality, effectiveness, and timely availability of services and provide evidence through examples in the hospital context. Benchmarking has its value and contribution when agile experiments and evaluation practices are elaborated, making it particularly suitable for the agile development of a design sprint (Knapp et al., 2016). Benchmarking was seen as a way to learn more about hospital management practices based on lean, agile, and human-centered approaches. In addition, in sub-study II, we found that benchmarking was experienced as one of the fastest and most costeffective approaches for a new hospital’s pre-construction phase, where the best practices for patient-centered care must be observed and investigated. Sub-study I stressed that the challenge of developing the benchmarking itself was strategically important and that there is a true need to adopt new practices to refine a benchmarking process especially in the service design field. As highlighted in the theoretical background of this research in subsection 2.3.2, the existing practical handbooks of service design do not offer tools or templates for benchmarking. Thus, implementations of and commitment to new design practices developed during and after benchmarking were experienced as difficult parts of the process. In the following paragraphs, I will discuss the three needs identified from sub-study I. First, there is a need for a required set of design tools to put ideas into practice. Here, the healthcare management had a need for visual ways to disseminate and communicate information from the benchmarking site visits to the local healthcare professionals, experts, and communities. Visualization and concretization tools (Koh et al., 2011; Shneiderman et al., 2013) are highly important during the benchmarking process but should be used more broadly. In sub-study I, we found that visualization tools helped to create a shared understanding of healthcare ecosystems, which can support the implementation of lean strategies in healthcare processes. In addition, through visualizations, we can aim to create better communication and participation. Second, when issuing mandates, there is a need to engage and commit people from the hospital, as noted by Wetter-Edman et al. (2018), who stressed that stakeholders’ participation is crucial and that we can impact and change their behavior. In sub-study I, benchmarking Alhonsuo: Early Phase of Healthcare-Related Service Design 96 97 encouraged healthcare staff from the Lapland Hospital District to discuss not only service design approaches in healthcare but also lean practices in the healthcare context. The practical examples helped hospital management and service design practitioners understand how a service design approach would be an effective part of healthcare-related development in hospitals. Third, there is a need for scaling up the service experiments in hospitals. Here, the service design practices and tools are ideal to zoom in and out to see the smaller details and the larger overview (Polaine, 2013). During some of the benchmarking site visits done during the first case study in sub-study I, hospitals ran their experiments first in one unit and later scaled them up for the other units. We argued in sub-study I that the scaling-up step is one of the challenges in service design and humancentered development. Scaling up services is part of the change process, which requires peer-to-peer learning. Here, transformational change in the organizational culture and management’s strong commitment to benchmarking are needed to ensure that the results of the service design process are discernable. The scaling-up step can take innovations from experimentation to implementation and strategic day-to-day management. The role of service design could offer solutions for meeting all the aforementioned needs. Service design tools can help to create and develop more effective benchmarking processes and generate support and commitment for service ideas, which affects the overall success of development projects. In sub-study I, we suggested that service design could use video personas and short commentaries and statements of healthcare professionals and patients from the benchmarked hospital and also develop tools for both designing and evaluating agile experiments based on benchmarking. The documented data from benchmarked hospitals can also provide evidence for the service development process and support the service designer in their role. This useful documentation could also bring service designers’ role closer to the early phase of the design process, when the designer can capture the contents and ideas generated during the benchmarking. The video recordings from the field and visual tools can also be valuable for internal purposes when aiming to improve the internal culture, initiating clinically meaningful changes in quality, and bringing about a “change in mentality” in an organization through benchmarking (Gleason & Bohn, 2017, p. 151). Alhonsuo: Early Phase of Healthcare-Related Service Design 98 4.1.2. Design Methods as a Way to Create and Share a Vision and Understand Ecosystems In sub-study I, we found that even though healthcare professionals in different municipalities were actively working together, they were still missing knowledge of the service processes in different hospitals. This challenge might make the services slower or even unobtainable, especially when a province consists of many municipalities that should seamlessly cooperate. Sub-study I demonstrated that visualization and concretization tools (Koh et al., 2011; Shneiderman et al., 2013) enabled better communication and participation in development processes and helped to create a shared understanding of healthcare ecosystems, which can support the implementation of such things as lean strategies in healthcare processes. In addition, as Hakio and Mattelmäki (2011) argued, participatory and visual design methods fit well into enhancing the cross-functional collaboration in a public organization. In the following paragraphs, I will stress the value of visualization and service design workshops especially from the very early phase of the development process. Eight municipalities were involved in the development process in case study 2 of sub-study I, where we determined that one of the biggest challenges is regional barriers. Information is missing from municipality to municipality, which makes the services slower or even unattainable. We visualized the resources as a blueprint template, which helped participants in the rehabilitation program share the information among the professionals, and through that, to perceive the healthcare-related service ecosystems of municipalities. In the service ecosystem levels devised by Beirao et al. (2017), the resource blueprint is linked to the micro and meso levels in this research. At the micro level, professionals inside the hospital shared knowledge and information, and at the meso level, professionals in other hospitals created an interaction and communicated together. The blueprint is a useful tool for managing complexity (Polaine et al., 2013), and therefore, the blueprint visualization as a concretizing tool amasses different data, knowledge, service processes, and the district’s ecosystems for everyone to view. Here, the resource blueprint was done at the beginning of the development project, and it was laborious but definitely required at the starting point. The information and knowledge were finally reachable and understandable, which helped not only during the development but also later to understand what service design tools and methods the service designer can bring to the development. As Vetterli and Scherrer (2019) Alhonsuo: Early Phase of Healthcare-Related Service Design 98 99 stressed, patient-centered innovations are difficult to reach for because the resources are limited and there is no consistent understanding of the current situation in organizations. The resource blueprint supports the structuring of these situations. The role of service design workshops was seen as a way to bring professionals “finally” together and, through design methods, to discuss and develop the health-related processes. As described in the second case study of sub-study I, the healthcare professionals saw the great value of having sufficient time to get to know each other and discuss among themselves. Although they might know each other by name and might also actively work together, for example, via phone or email, they may never have met face-to-face. The professionals from the rehabilitation field were curious to know more about the services, processes, and the entire district’s ecosystems as well as the resources and how these were distributed in the municipalities. In sub-study I, we discovered that workshops are not only a great platform for meeting people, but they also generate value for further development projects and increase motivation for service innovations. Workshops as a co-design platform are also crucial when developing healthcare processes across municipalities, when it is crucial to foster trust, clear communication, and familiarity with other professionals. Here, the role of the service designer is particularly important for achieving equal, high-quality, and creative cooperation. 4.2. Patients’ Experiences of Healthcare Services Sub-study II answered the following research question: How are patients’ experiences considered when designing new hospitals and healthcare services? Previous studies found that there are potential benefits of utilizing patient-centered co-design in the healthcare environment (e.g., Donetto et al., 2015). This potential was also clearly recognized in both hospitals in sub-study II, but the results revealed the existence of various challenges and different opinions concerning patient involvement and co-design methods, especially in the early phase of the new hospital construction process. In addition, due to schedule limitations, patient-centered codesign sessions were difficult to utilize, and the co-design methods were not optimal for every issue or phase. I will now discuss these issues more thoroughly in the following paragraphs. Alhonsuo: Early Phase of Healthcare-Related Service Design 100 Limited Timescales and Resources Even though the data in sub-study II were limited and collected from two hospitals (H1 and H2), they clearly indicated that there are no common practices in patient involvement when designing new hospitals. One of the notable results from sub-study II concerned limited timescales and resources in the use of co-design and patient-centered methods. Limitations of time and resources were mentioned as having the biggest impact in a context of bringing co-design into the long-term process of new hospital design, which is executed under time-schedule pressure and under the guidance of architects. It was noted that the schedule for the planning phase is usually so tight at the beginning that there is not enough time to go through all the processes in the hospital. In addition, in a silo-structured organization, the healthcare professionals are often optimized in their own area of expertise and, thus, there are challenges in wards being able to “discuss” among each other. This causes problems when the focus should be on the overall caring process, where the patient is the main stakeholder who has to experience the entire process from one silo to another. The impact of co-design methods and their challenges have been investigated in prior works (e.g., Bowen et al., 2013; Canham et al., 2016; Pirinen, 2016). As identified by Canham et al. (2016) participants over-estimating the potential scope and time scale for change is a main challenge with co-design methods in the healthcare context. In addition to these issues, which were also recognized in sub-study II, one of the mentioned struggles was designing something totally new in a hospital. Concretizing the Environment Another key finding of sub-study II concerned concretizing methods or more specifically, concretizing the environment. Here, H2 used VR workshops to concretize the service ideas in the new hospital. They structured the VR sessions so that the hospital staff first tested and evaluated the essential apparatus and equipment, and subsequently, in the second VR session, they invited patients to give their opinions. They also invited people from the customer jury without any specific experience of the redesigned room and people with real-life experience. Thus, they could gather different observations and comments that were truly relevant. This sub-study showed that VR, as a way to concretize service processes and physical touchpoints, supported the development of physical solutions. Alhonsuo: Early Phase of Healthcare-Related Service Design 100 101 A VR co-design session can add realism to simulated environments and is an inexpensive way to test, ideate, and develop service scenarios and physical mock-ups, such as isolation rooms or self-registration machines. In addition, VR simulations and physical mock-ups as co-design practices can not only visualize the floor plans and equipment layout issues but also elicit the people’s voices. As a low-tech version of VR technology, H1 used a physical replica that was built in the parking lot of the hospital. The healthcare staff could visit, concretize, and test different apparatuses and equipment in this context, and feedback was collected and utilized for further use. No patients or customer jury were allowed in the location of the physical replica. The approaches of VR technology and physical replicas are linked to prototyping practices, which are popular methods in service design. When healthcare professionals can test out some new ideas through physical replicas, the ideas develop in their minds afterwards, and they make many suggestions later. This causes difficulties during the construction process, because any changes also affect technical issues. Knapp et al. (2016) also wrote about this phenomenon in design sprints, specifically regarding when you should better utilize the time working alone, for example, in the evening, when the mind is still engaged in thinking about what has occurred. At the same time, this should be considered in the schedule, where you first test the physical replica and then introduce your suggestions and ideas the day after. These prototyping practices are not a new area in healthcare development. There are good examples presented from the cardboard hospital by Kronqvist et al. (2013) and how the real-sized prototyping environment could be part of the building design process with other evaluation methods, such as virtual simulations and test prototypes constructed of wood panels. As another example, Kronqvist et al. (2013) suggested gamification methods to bring patient-centered and holistic understanding into healthcare development. Here, patient experiences were discussed through the customer journey as a game board, which assisted the patients in the interviews in remembering, understanding, and discussing their experiences. The game board method could also be utilized to develop the new hospital construction process, where patients’ lived experiences should be considered. The game board or, similarly, a desktop walkthrough helps to perceive, for example, distances when the real-size prototyping or VR helps in testing out the details in a specific moment, such as a visit to a treatment room. To link these methods, we followed a continual process of service design practices, where we zoomed in and out to see the details Alhonsuo: Early Phase of Healthcare-Related Service Design 102 and overviews (Polaine, 2013). Benchmarking the Co-design Methods Sub-study II examined the use of benchmarking to adopt the best practices for patient-centered care in the early phases of new hospital design, which was actually done in H2. They used time to observe how other hospitals utilized different co-methods and good practices to further their own construction projects and duplicated them in their practice. As a comparison, H1 acknowledged in hindsight that it would have been beneficial to have more resources, time, and co-design methods for the planning phase. Moreover, during the early development phases, both hospitals utilized the customer jury, which consisted of citizens whose role was to represent the patients. The value of having patients as part of the co-design process was seen differently. H2 saw a lot of value in involving real users in the process and, therefore, nominated a person to investigate service flows, especially to ensure that the hospital’s operation was effective and patient-centered. They also organized workshops with patients, seeing their involvement as crucial during the design phase. Conversely, H1 did not see much value in this in the early phases, stating that there might be too many different opinions. In addition, sub-study II found that the data from customer jury meetings or workshops was not always further processed and utilized. Here, as an example, H1 organized a workshop with the customer jury, but the data were hardly used, if at all. It was also observed in sub-study II that in the workshops that did not include patients, the healthcare professionals sometimes shared their own knowledge based on the feedback they had personally received from patients. This feedback considered issues in the treatment process or details of the hospital building. The workshops were moments to remember and opportunities to share feedback. This observation indicates that patient experiences are important for healthcare professionals even if the patients themselves are not present to share them. 4.3. Strengths and Weaknesses of Health-Related Design Sprints Sub-study III examined the following research question: What are the strengths and weaknesses of health-related design sprints? The sub- Alhonsuo: Early Phase of Healthcare-Related Service Design 102 103 study was conducted through three design sprints run in three hospitals in Sweden, Estonia, and Finland, respectively. Findings from the collected data (research diaries, field notes, and interviews) highlighted six strengths and three weaknesses from the participants’ points of view (Table 5). Using these as themes, we categorized them into two main result areas: (1) challenges for change in design sprints and (2) synergy in agile ways of doing. In the following paragraphs, I will discuss these two areas in more depth. Table 5. Strengths and weaknesses from design sprint participants’ perspectives. Challenges for Change in Design Sprints The role of service design in healthcare has become important. However, the changing world of new technologies, aging populations, continuous growth, and social and healthcare reforms (e.g., Clack & Ellison, 2019; Fry, 2019) are challenging healthcare-related service design. Obviously, a design sprint alone is not a solution for tackling these challenges, but it can open new opportunities in the healthcare field. Learning was highlighted as the greatest strength in the health-related design sprints, which was strongly linked to design thinking and design methods, and it was shown that it can support change in co-design processes and services (Kuure et al., Strengths and weaknesses from participants’ points of view Strengths Weaknesses - Learning design thinking and design methods - Organizational change - Dialogue between stakeholders associated with different design methods - Understanding hospital processes from the end user’s perspective - Emphasizing stakeholders by employing co-designing - Other relevant insights regarding hospital services - Understanding the bigger picture of hospital processes and systems - Relevance of the created service concept - Ethical limitations and considerations Alhonsuo: Early Phase of Healthcare-Related Service Design 104 2014). Participants (both healthcare representatives and students) learned to use design methods in different phases during the design sprint process, and this also increased their capabilities in design thinking. Learning occurred within the design sprint teams when important knowledge could be immediately shared. In addition, the healthcare professionals were motivated to implement some of the design methods in their everyday practices, which had an impact on the transformation when design tools and skills were part of the organizational capacity for ongoing change (Burns et al., 2006; Sangiorgi, 2011). One of the challenges for change in healthcare organizations is failing to learn from failures (Edmondson, 2004; Fry, 2019) and avoiding or managing risks and/or costs (Clack & Ellison, 2019; Fry, 2019; Jones, 2013). In this sub-study, one viewpoint was to focus on the roles of role-playing and prototyping when testing different service concepts. Role-playing enabled us to test ideas in a safe environment and iterate them further— this also included failing and learning more about risks. In addition, it was easier for healthcare representatives to suggest features and understand how technology fits in healthcare processes. Service prototyping can be said to be “quick and dirty,” which is an explorative and “goal-oriented but playful way” (Schulz et al., 2015, p. 323). It is so “low-tech” that suggestions for better development ideas are easier to express. In addition, very limited time frames in the design sprint process kept the prototypes very rough. We used mentoring in our design sprints, where the healthcare professionals and experts from different wards of the hospital visited design sprint teams to share their knowledge, motivation, and ideas. Mentoring can be a crucial part of healthcare-related design sprints when the organization is silo-structured and complex. Thus, we carefully selected the mentors for their open-mindedness and willingness to facilitate changes in healthcare. As hierarchical and silo-structured organizations prevent growth (Donetto et al., 2015; Fry, 2019; Radnor et al., 2012), through design methods, we enabled a platform for professionals to discuss their experiences and perceive a holistic picture of healthcare services, especially from the patient’s point of view. The concrete design methods, such as visualizations methods, storyboards, and desktop walkthroughs, supported the understanding of holistic service journeys and emphasized the stakeholders not only from the patient’s perspective but also from that of the hospital professionals’ daily work life. Thus, it was important to have a concrete and real picture of where the service would be delivered. Design methods also supported the dialogue among participants, especially during the mentor visits. Alhonsuo: Early Phase of Healthcare-Related Service Design 110 111 Table 6. Key findings from sub-study I Sub-study I highlighted two main areas that are relevant for this research question. Benchmarking as a tool to develop hospital management practices: Benchmarking is valuable for evidencing different management practices based on lean, agile, human-centered approaches and quality, effectiveness, and timely availability of services. Benchmarking also contributes when developing agile experiments and evaluation practices. It is a fast and costeffective approach for understanding the best practices for patient-centered care, especially for the new hospital pre-construction phase. The design field is lacking structured practices and tools to do benchmarking in complex organizations. Thus, we identified three crucial needs: - The need to engage and commit people from the hospital to be part of the benchmarking, for example, how healthcare professionals could be more actively involved in data collection during benchmarking or how they could be experiencing benchmarked processes. - The need for adopting healthcare-related benchmarking practices and tools in service design, especially the implementation of and commitment to these during and after benchmarking. Here, we discussed the roles of visualization, video personas, and short commentaries and statements from the benchmarked hospital. - The need to learn new ways to scale up service experiments in hospital environments, such as how the service innovations could be tested for agile in different wards and applied to these different environments. Design methods as a way to create and share a vision and understand ecosystems: Healthcare professionals are missing knowledge of service processes from different hospitals, which might make the services slower or unobtainable. Furthermore, visualization and concretization tools not only support communication and participation but also foster understanding of the healthcare ecosystems through silos, municipalities, and regional barriers. The resource blueprint is a tool to perceive different ecosystems and their layers. In addition, it makes information sharing and service development easier through regional barriers. Service design workshops provide a great opportunity to finally bring people together to meet each other. Workshops generate value for further development projects, increase motivation for the service innovations, and promote trust, clear communication, and familiarity with other professionals. Alhonsuo: Early Phase of Healthcare-Related Service Design 112 Table 7 introduces the key findings from sub-study II and answers its research question: How are patients’ experiences considered when designing new hospitals and healthcare services? Table 7. Key findings from sub-study II. The results from sub-study II indicated the existence of a variety of challenges and different opinions about patient involvement and co-design methods especially in the early phase of the new hospital construction process. Here, I describe the three main themes we determined. Limited timescales and resources in the use of co-design and patientcentered methods were stressed as one identified challenge, which also had an impact in the context of bringing co-design into the long-term process of a new hospital. In construction projects, the time pressure is tight, especially at the beginning, and thus, there might not be enough time to go through all the processes. In addition, healthcare professionals are optimized for their expertise, which supports the silo structure. Overestimating the potential scope and timescale of changes was seen as critical in co-design methods, especially when designing something totally new. Concretizing the environment, especially in a new construction project, was defined as a challenge. VR co-design workshops were utilized and found to be a good method to outline spaces by adding more realism. It was an inexpensive way to test, ideate, and develop service scenarios and physical mock-ups. Another example was to build a physical replica. Benchmarking was used in this sub-study to adopt the best practices for patient-centered care and co-design methods. Alhonsuo: Early Phase of Healthcare-Related Service Design 112 113 Table 8 summarizes the key findings from sub-study III and answers its research question: What are the strengths and weaknesses of healthrelated design sprints? Table 8. Key results from sub-study III. Challenges for change in design sprints - Learning was seen as a strength in design sprints, which was linked to design thinking and design methods. Some of the design methods learned during the design sprints were implemented in the everyday practice of the hospitals by healthcare professionals. - Role-playing enabled us to test service ideas in a safe environment and iterate them further. This had an impact on failing and learning more about risks. - Healthcare professionals and experts, who were carefully selected for their open-mindedness and willingness to facilitate changes in healthcare, mainly participated as mentors in the design sprints. - The design sprint did not allow participants to focus on the entire healthcare process in depth, making issues related to governance, strategies, political will, and economics the most difficult to consider. Thus, the design sprints in some cases had negative effects on concept ideation, trust, and the relevance of the final outcome. - Participation was highlighted as the most important way to achieve change inside a healthcare organization when healthcare representatives, various experts, managers, participants from different backgrounds, and designers develop together. Synergy in agile ways of doing - The facilitator’s role was crucial for boosting synergy within the design sprint teams. Synergy and dialogue among all people involved were more important than the end result itself. - Well-facilitated processes, carefully selected design methods, and openminded mentors create synergy, which helps to overcome challenges associated with making changes in the healthcare sector. - Respect must be created for everyone’s knowledge, skills, and profession. Design methods worked as a platform for applying these skills, and through that, trust and mutual learning were generated within the team. - Design sprints were seen as an example of or short introduction to the design field, a kick-off for new hospital projects, or a booster during the middle phase of a project, not aimed at achieving concrete outcomes for implementation. - The design sprint approach familiarizes people inside an organization with what can be aimed for and achieved with design practices and how the different design methods can systematically build knowledge, define insights, and create solutions. Alhonsuo: Early Phase of Healthcare-Related Service Design 5. Discussion 114 Lastly, the key results from sub-study IV are highlighted in Table 9. The sub-study’s research question was as follows: How can healthcare representatives support design sprints in the development of healthcarerelated services? Table 9. Key findings from sub-study IV. We identified four roles for participating healthcare representatives: team member, learner and design thinker, mentor, and facilitator. These identified roles were the basis for the development of a four-theme framework that could be used for co-design and human-centered design sprints. The themes are briefly introduced below. Learning and knowledge sharing This involves not only gaining a better understanding of methods in the design process but also learning to understand, apply, and use design methods and design thinking in future work. Design thinking, support, and participation Designers (often also facilitators) guide dialogue, support the usage of design methods, help to empathize with people, and select the best possible tools for understanding the data, their insights, and outcomes. Power sharing and mentorship Experts can clarify the complex and multi-layered healthcare processes for students who can then gain deep insights into the healthcare systems as a result. Facilitation The role of facilitator is crucial during the design sprint process, where different skills are needed to achieve the aims or planned outcomes. Facilitators need to understand how to approach the design brief, how to apply different design methods, how to collaborate with participants from different fields, and how to manage tensions and conflicts during co-design. Alhonsuo: Early Phase of Healthcare-Related Service Design 5. Discussion 114 115 This doctoral dissertation focuses on answering the main research question: How can service design and co-design approaches support the early phase of healthcare-related service development? I have addressed this question through the four sub-questions formulated respectively in the four sub-studies which have provided the basis for my research. The substudies, which answered these sub-questions, were introduced in depth in the previous sections, each ending with a short summary. In this section, I will first reflect on the main research question in terms of my theoretical background and then propose a practical framework for the early phase of healthcare-related service development, discussing it through the lenses of objectives, impact and values, and design methods and tools. In addition, I will highlight the service ecosystem levels and how the practical framework helps to outline these different service ecosystem levels. This understanding can be utilized especially when planning a design process for healthcare-related service development. 5.1. Preliminary Preparation and Evidence Previous studies have discussed where service design should have its place and impact in the development process (e.g., Almqvist, 2017, 2020; Clatworthy, 2013; Raun, 2017; Yu & Sangiorgi, 2014). In fact, some of the recent literature has noted that the early phase of the design process, the so-called fuzzy front end, has already been investigated, and it is, therefore, time to focus on the later phases where implementation occurs. It has also been critically stated that different design-led processes and toolboxes have Alhonsuo: Early Phase of Healthcare-Related Service Design 116 been the only outcomes of organizational development and design has not reached the desired capacity (Holmlid & Malmberg, 2018; Malmberg, 2017). However, the front end is the most information-intensive phase, where different types of information from internal and external sources are brought into the project (Zahay et al., 2004) and the major decisions are made (Clatworthy, 2013); thus, we should put more effort into the early phase. It is also a moment where the team members get to know each other and the given brief and the team plans the details of the project. In this research, preliminary preparation was provided through benchmarking and preparing the benchmarking data and design sprints. The sub-studies introduced in this research found that there are elements that service designers should consider before starting a healthcare-related service development project. These elements are related to building trust and engagement among participants; understanding the service design and co-design; learning design practices, processes, and methods; and adapting the process to the everyday work practices. From the service design and co-design points of view, the preliminary preparations aim to evidence the potential of service design and the value of co-design through the entire development project and to avoid leaving the designers outside of the project with the important and deepest insights of the users in their hands, as Almqvist (2017, 2020) has explained. The different roles and participation of service designers and other stakeholders can then be justified more clearly throughout the project. In addition, the preliminary preparations aim to avoid fuzziness at the beginning of the service development project. When the groundwork is planned, evidenced, and prepared well, we can establish a better understanding of the object to be developed on the basis of the initial knowledge and consequently provide more evidence for the organizational and design levels before the actual development project begins. According to Foglieni et al. (2017), evidence is needed for decision-making at both the organizational level and the design level, which helps to drive learning, change, and transformation step-by-step. At the organizational level, the evidence can be utilized while planning the structure of the design process for service development and creating a common understanding from it. The following questions can then be considered: What is the aim of development in complex organizations; what is included and excluded in the brief; how can we define the service under development; and what are the resources of each ward/hospital from the service development and process engagement points of view? In this research, evidence was gathered through service design Alhonsuo: Early Phase of Healthcare-Related Service Design 116 117 methods, where the data collected from the field, for example, through benchmarking or questionnaires, were visualized by using different mapping tools. These mapping tools can be, for instance, service journey mapping or resource blueprints, which were also utilized and analyzed in sub-studies I, III, and IV of this research, and they can be beneficial for development especially in the beginning of the process. In addition, through other concrete design methods, such as prototyping and desktop walkthroughs, evidence can be created when concretely describing the experiences of stakeholders or stepping into the shoes of another. In this research, I saw the evidence as being concretized and observed strategic benchmarking process and visualization tools helping to perceive the complexities in the silo-structured organizations. The value of using benchmarking is that it builds evidence that is gathered from other (healthcare) organizations. The evidence from the benchmarking can be, for example, how other organizations are producing a service, how the change has been implemented in an organization, or how they have successfully utilized and used design methods as part of service development. Benchmarking is already well known in the healthcare industry, where it has been used over the years for quality in healthcare services (Kay, 2007), and thus, the leap into new approaches is not significantly different. The potential to further develop the benchmarking processes, visualization tools, and prototyping methods for both designing and evaluating agile experiments based on benchmarking exists. As prototyping saves resources, such as time and money (Blomkvist, 2014), it could be a beneficial tool in benchmarking, for instance, during new construction projects or in agile experiments during the design sprints in the early phase. However, combining this benchmarking into visualization and prototyping requires preparations for which the service designer has expertise. As emphasized in sub-study I of this research, healthcare management has expressed a clear need to find visual ways to disseminate and communicate benchmarking information to larger audiences in their home communities. Therefore, the design sprint with prepared benchmarking evidence could be one successful way to disseminate and communicate information. Service design could, for instance, focus on using video personas and short commentaries and statements from individuals met during the site visits or on generating the digital benchmarked data for VR. The usage of VR in healthcare service development was found to be a good practice in sub-study II. Alhonsuo: Early Phase of Healthcare-Related Service Design 118 5.2. Familiarization with the Unknown Challenges to change arise when healthcare organizations aim for innovation and development (e.g., Fry, 2019). Even though healthcare and design have had a long history together in healthcare service improvement (Rowe et al., 2020), studies have shown that the field is still lacking knowledge of, for instance, selections of participants for co-design workshops (Boyd et al., 2012) and communication about design in terms of healthcare terminology, trust, and shared understanding (Hakio & Mattelmäki, 2011). In addition, issues such as the risk of losing credibility or fear of design practices may exist (Hakio & Mattelmäki, 2011). As noted in the literature, service design is studied to be a catalyst for organizational change and transformation (Junginger, 2015; Yu & Sangiorgi, 2018), and it would be valuable to involve and engage healthcare professionals who are interested in and curious about design. There is a need to have these professionals from the healthcare field as part of the service design process to impact and change the behavior of stakeholders (Wetter-Edman et al., 2018). Service design, as a development approach, might be a strange way of working for several practitioners in the field of healthcare and it, thus, raises many questions and uncertainties. Nevertheless, the curiosity and suspicion about service design did not go unnoticed during the substudies of the research. There is a true need to provide new initiatives for the early phase of the service development process in complex healthcare organizations and aim for better and more efficient cooperation. The goal here is to familiarize people from the healthcare field with service design and co-design so they can better contribute to the project planning and suggest how the methods can be better adapted to their everyday practices during the design process for service development. This is important when working with people who are busy and often overburdened with their work. This research indicates that an intensive design sprint is a way to support healthcare-related service development through service design and co-design approaches. It is seen here as an example to introduce the design process, design methods and tools, and what can be achieved through them. The overview of the design process introduced through a design sprint gives value to several issues. As highlighted in sub-studies III and IV, a key element for understanding, applying, and using design methods and design thinking was learning to use design methods. An agile way of hands-on doing created a synergy among participants, Alhonsuo: Early Phase of Healthcare-Related Service Design 118 119 professionals, and experts from different silos who were involved and engaged in sharing their knowledge and insights. They learned to use different design methods and they understood the value of visualization, especially from the viewpoint of complexity. Most importantly, the design sprint was not only valuable for the upcoming project planning but, as the findings of sub-study IV stressed, the design methods used during the design sprint were transferred to everyday work and were not used only for the purpose of achieving the goals of the design sprint. This might also have an impact on the emergence of completely new types of design methods in the healthcare field when they are co-designed by designers and healthcare professionals. Design sprints would add even more value to the service development process if management were better involved. Change or transformation in an organization happens through learning (Kuure et al., 2014), and one of the most powerful ways to achieve change is for organizations or communities to start steering changes themselves (Sangiorgi, 2011). From this point of view, the role of management is particularly important, and thus, it should not be underestimated or completely ignored. It is unfortunate that sometimes projects that are carried out in cooperation with academic, design-driven case studies get approval from management, but there is no further interest from management thereafter in participation. Although healthcare professionals may be enthusiastic about service design and creative co-design methods, their implementation and, thus, the culture of change are not taking off. For this reason, staff management is necessary when changes must be adopted and implemented in the healthcare staff’s work life (e.g., Nilsen et al., 2016; Stickdorn & Schneider, 2011), and one way to better engage them is to familiarize them with the unknown. Here, an agile and intensive design sprint (e.g., Knapp et al., 2016) offers a quick overview of the design methods and design process, but above all, through a rigid and facilitated process and elements of agile, design, and lean thinking, the design sprint teams learn to produce a minimum of viable services (Magistretti et al., 2019) and implement the design practices for future service development projects. In addition, agile experiments have value when failures occur in a safe environment, before actual implementation. Failing is seen as a risk in healthcare, as failure might lead to a patient’s death (e.g., Edmondson, 2004). For that reason, design sprints are good opportunities to advance cultural shifts in organizations where failure can be handled safely (Kutvonen, 2017), and thus, design sprints can be a major starting point in the development of healthcare services and in a design-centric cultural change. Alhonsuo: Early Phase of Healthcare-Related Service Design 120 As explained in sub-studies III and IV, design sprints should rather be seen as an example of or short introduction to the design field or a kickoff for new hospital projects, not aimed at achieving concrete outcomes for implementation but, rather, at understanding what can be aimed at and achieved with the design approaches, and systematically building knowledge, defining insights, refining research questions, and creating preliminary solutions. In addition, in perceiving more realistically which service ecosystem levels the development project reaches, we can plan better how many resources we need, how large a collaborative network we should create for the project, whom we want to involve in the project, and, for example, how much time is needed for the project. 5.3. Practical Framework for Healthcare Service Development Service design has the potential to support healthcare-related service development especially for complex, silo-structured, multi-stakeholder services, where processes, resources, management structures, and visions should be better understood. As a result, it is important to realize, for instance, the resources, time, and design methods required for the service to be developed. There are no right solutions or approaches to facilitating the design process for healthcare-related service development, but there are issues to consider that support the starting point and, thus, help in further phases when the actual design process for service development starts. The following Figure 20 illustrates the location of the practical framework in this research and its three steps. The practical framework is called Pre-phase for healthcare service development. Alhonsuo: Early Phase of Healthcare-Related Service Design 126 127 This will require, among other things, the decision regarding the service to be developed to be made between the partners—in this example, Estonia, Sweden, and Finland. The aim of the Co-designing healthcare project was to educate more designers to gain service design experience in the healthcare sector, and also to educate healthcare provider to use “design as process” and “design as strategy”. This cross-border collaboration with the healthcare sector, the design industry, academia, and other relevant collaborators can be a key to macro-level changes as more evidence emerges of the potential for service design and co-design approaches. These three design sprints also strengthened the healthcare-related design network through international, academic collaboration that has remained strong since the projects. With these projects, service design and co-design can be learned in complex healthcare environments no matter how simple or demanding the object to be developed is. In addition, the design will be brought closer to the healthcare field and the professionals working there. I also believe that small micro level changes have long-term positive effects on both meso and macro level changes, and as discussed in sub-study I, Service design and its multiple methods are a good option when designing new healthcare services, especially when these combine various healthcare ecosystems. Service design tools create entry points and platforms for developing shared understandings and insights and negotiating reforms of healthcare practices and patientcentred processes. (Miettinen & Alhonsuo, 2019, p. 494) Alhonsuo: Early Phase of Healthcare-Related Service Design Picture: Maileena Tuokko 128 Alhonsuo: Early Phase of Healthcare-Related Service Design 6. Conclusions 128 129 6.1. Impacts of the Research The novelty of this research is its introduction of a practical framework for the early stage of the development process. The impact of the framework relies on several issues. First, it can foster the role of service designer from the beginning of the development process and—instead of what Mulgan (2014) stressed as designers having a “lack of attention to organizational issues and cultures” (p. 4)—aim to increase the knowledge and attention to organizational issues and cultures. This knowledge in designers’ hands could help service designers to better plan the entire design process, not only touching on the operational levels but also involving the strategic levels at the earliest possible stage. I believe there are design tools that clearly have a stronger impact on the strategy of an organization and should play a more important role in the complex service design. Benchmarking, which was also introduced in this research in sub-study I, emphasizes one of these methods and should be further investigated. I also believe that by engaging healthcare professionals in the early phase of service development, more specifically in the pre-phase of healthcare service development, they have a more important role in influencing not only the planning and scheduling of the development process but also the application of the design methods used in busy healthcare work. Medical and nursing education utilizes simulations, which is not a new teaching method in healthcare (Poikela, 2017). Furthermore, hospitals are using scenario-based simulation training in their everyday practices. These simulations have similarities to service prototyping, and Alhonsuo: Early Phase of Healthcare-Related Service Design 130 so there is place to adapt the two to each other. In addition, lecture and teaching input on service design has been increasingly sought in nursing education, at least at the Lapland University of Applied Sciences. Thus, service design could have an impact on nursing education by adapting its approaches to the learning programs. In addition, collaborating healthcare-related service development with nursing and design education and professionals from the healthcare field might have an impact on the future where innovation is no longer seen as disruptive from the point of view of being a risk to clinical service, as Jones (2013) and Clack and Ellison (2019) have explained. The ways of collaborating through service design and co-design can bring professionals from different silos together and, thus, avoid hierarchy being an obstacle to growth (e.g., Donetto et al., 2015; Radnor et al., 2012). Improving and increasing the understanding of design-centered approaches at the educational level might also have an impact on the strategic level of the healthcare sector: the more you recognize these creative approaches, the easier it is for the designer to get involved in the service development process. 6.2. Suggestions for Further Research Healthcare is a complex and multi-layered field that offers many designrelated opportunities and interplays between different service levels. Its siloed structure enables a great platform for service design to tackle many different cases. When summarizing the sub-studies of this research, the opportunities for future investigations became obvious. Here, I would like to again emphasize the role of benchmarking through the service design approach as a way to develop healthcare-related services. A well-known service design method is prototyping (e.g., Blomkvist, 2012; Coughlan, Fulton Suri, & Canales, 2007; Holmlid & Evenson, 2007), where service scenarios are simulated through role-playing or concretized through paper-based or Lego Serious Play desktop walkthroughs. These help people play through the service experiences before establishing them in an organization (Holmlid & Evenson, 2007), which can be a way to bring more evidence into the development process. According to Fry (2019), new initiatives need more evidence. There is great potential to investigate how well we can bring evidence into development when we benchmark healthcare services through prototyping. In the service design field, service prototyping has shown good outcomes in learning (Kuure & Miettinen, 2013) and transformational change in the case of social services (Kuure et Alhonsuo: Early Phase of Healthcare-Related Service Design 130 131 al., 2014), which, compared with healthcare services, also has some complex and silo-structured elements. According to Blomkvist (2012), prototyping can be conducted at four levels: (1) artifact, (2) use, (3) context, and (4) service levels. These levels could offer a way to fractionalize the complex process while making it observable and concrete through benchmarking. During the Nordplus Horizontal project (where the design sprints described in this dissertation were conducted), our project partners had a meeting in Rovaniemi. The initial plan was to go on a road trip to all three locations—Tallinn, Gothenburg, and Rovaniemi—and benchmark the local partner hospitals before undertaking the actual design sprints. Due to some difficulties in finding suitable time slots for the road trip, we decided to meet in Rovaniemi, leaving Tallinn out of our trip itinerary. I was inspired by the possibility of bringing the hospital experience through prototyping from Tallinn to Rovaniemi. I asked our partners from Tallinn to go to the hospital and take pictures so they could create a service journey. I gave them instructions on how to take pictures so that we could walk through the hospital in the simulation laboratory (SINCO – Service Innovation Corner) located at the University of Lapland, Faculty of Art and Design (Miettinen, Rontti, Kuure & Lindström, 2012; Rontti, Miettinen, Kuure & Lindström, 2012). The experience of walking through the local hospital of Tallinn in the simulation environment in Rovaniemi received a lot of positive feedback and showed that this type of experience is something that should be developed further (Figure 22). Figure 22. Benchmarking through service prototyping in SINCO-lab, University of Lapland. (Pictures: Maileena Tuokko) Making benchmarking more realistic for the early front-end phase and showing how the services are run in different locations or how the details are structured can help with the starting point. Benchmarking is also a Alhonsuo: Early Phase of Healthcare-Related Service Design 132 relevant method for service designers to understand the variations of complex healthcare services and perceive the patients’ journeys and different actions from healthcare professionals. Although benchmarking is not a new method in the healthcare field (Kay, 2007), it still has huge potential to be even better through a service design approach. Service design can supply the benchmarked location with more concrete, story-based, and timeline-related action, which is easier to understand, experience, ideate further, and, most of all, accept. In addition, the digital solutions for documenting service experiences will play a crucial role in future benchmarking. This topic has true value and will provide great opportunities for further research. Another area for further research is related to systematic visualization methods, linked to benchmarking data from other hospitals as well as the hospital that is under development. There is a need to go further with these methods, which help to perceive at least the following areas: (1) the service as a timeline blueprint with service moments for patients, healthcare providers, and other crucial stakeholders, such as physiotherapists or social service providers; (2) a resource blueprint that better mirrors the possibilities in the developed location; and (3) visualizing the crucial touchpoints so they are easier to understand and even test. Systematic visualization needs more research to be framed as a ready-filled template that fits well with different hospital service structures. This will support the strategic initiatives of healthcare. Finally, I would like to point out that there are many possibilities for going even further with design sprint processes that are specifically designed for the healthcare field. Here, I want to emphasize the roles of different participants and the skills of facilitators and that the design sprint could be a monthly, biannual, or annual practice of healthcare development. The design sprint has its space and time—with the people who are willing to be a part of it being the most important factor. This could be a great way to implement design practices, service design methods, and design thinking as a conventional practice in the healthcare field. Alhonsuo: Early Phase of Healthcare-Related Service Design 132 133 ReferencesReferences Adams, P. (2003). Thinking skills and constructivism. Teaching Thinking, 10, 50–54. Adams, P. (2006). Exploring social constructivism: Theories and practicalities. Education, 34(3), 243–257. Alam, I. 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