PART III

Rethinking Care Systems

The final four chapters examine the human-centered and systemic design necessary for “backstage” processes of health services design and delivery. These focus on care practice and education, as professional practices and as human systems and services.

The Care Services Landscape

In developed economies, the services sector has surpassed the manufacturing and goods production sectors in terms of revenue size and employment numbers. Yet costs have significantly increased in service provision, especially in healthcare, affecting perception of value, consumer demand, and even employment. The increased costs in healthcare services have led to a societal contract in which health insurance is necessary to ensure even the possibility of adequate care. As service is decoupled from the reality of consumer affordability and coverage, however, this social contract will break down, even in countries with lower base costs than in the United States. When consumers have unequal access to healthcare services due to the unavailability or costs of insurance, then new service systems for healthcare must be designed, with some forms of healthcare service provided as public goods.

In any market, service providers often aim to dominate their service ecosystems with superior customer retention and perceived value in order to keep a sustainable advantage in their market. The healthcare sector is no different—health seekers (consumers) have choices, and large institutions are constantly seeking to differentiate their service offerings and quality. Yet the vision of service innovation has been slowly achieved in healthcare, especially when compared to the pace of technological innovation.

Services innovation aims for transformative changes in patient experience, business models, and the very role of the provider. Innovation produces change at the level of service or system management and embraces all types of creative resources, not just design-led processes. Experience design methods offer a design-led framework, but these are only half of the opportunity. System-level innovation requires stakeholder process design, service system design, new models of practice management, and community engagement.

The Health Seeking Journey in the Care System

In the shift “up-system” from the health seeker to the healthcare system, we encounter increased complexity. The human-centered design approach and user-oriented methods underserve this complexity because they design for optimal individual experience. A hybrid of systems and design methods are needed to achieve integration with health system touchpoints as suggested in the health-seeking journey in Figure III.1. This diagram interprets the primary patient encounter with these systems experienced by both patient and clinicians.

The backstage operations of a big box clinic may employ hundreds of people in specialized roles. Once Elena enters the hospital as a patient, she interacts with a handful of staff for a brief period. The service she enters at each stage represents a self-contained clinical encounter with different clinicians and locations for each appointment and procedure.

Here the touchpoints (in a health system context) indicate information collected for each encounter. Elena’s scenarios in these chapters complete the journey through services—from the diagnosis of a major cardiac issue to living with and managing the complexity of her personal health condition—as she deals with:

• The changes in lifestyle and behavior required at each touchpoint.

• The contradictions between her health-seeking needs and the stress of adhering to medical orders.

• The contradiction between her shift from caregiver to family patient.

• The need to make choices of treatment and procedure that have significant life impact.

Even within many health networks today, patient information is not integrated across services, making a fragmented trail for patients in their clinical health-seeking journey. Each resource is an independent and often isolated data processor serving functions for that touchpoint only. Service continuity across clinical encounters remains a significant challenge, and one that may not improve as healthcare organizations transform into regional networks of smaller clinics with dedicated purposes.

FIGURE III.1
The health-seeking journey as navigating the care system.

Design goals at the healthcare service system level include larger-scale interventions:

• Designing information system platforms as multifunction backbones to integrate multiple vendor applications in a common data model

• Designing health services as processes across departments within institutions to enable flexible workflow

• Redesigning information practices to coordinate patient health data, requests, feedback, and outcomes across clinical providers

• Co-design at the community level to mitigate chronic health problems through early intervention

• Providing integrated design, research, and human factors advising, communications, and workshops with clinicians and public health researchers to enable redesign of services and clinical work processes