Designing the Future, Engineering Reality: Prototyping in the Emergency Department - Starnino, Dosi, Vignoli

ServDes 2016 – Copenhagen, Denmark !

DESIGNING THE FUTURE, ENGINEERING REALITY Prototying in the Emergency Department Clio Dosi, Antonio Starnino, Matteo Vignoli University of Reggio Emilia and Modena, Reggio Emilia, Italy

Body Level One !

Design innovation branch of the University of Reggio Emilia and Modena, Department of Management engineering. SECTORS: • Healthcare • Food technology • Embedded design thinking in organizations • DT Education

DESIGN THINKING UNIMORE!

EVALUATIVE SERVICE PROTOTYPING IN AN EMERGENCY DEPARTMENT

Our case study explores the role of service prototyping to test complex service systems.

In particular, we explore the role of evaluative holistic prototyping.

SERVICE PROTOTYPING: HOLISTIC AND SINGLE

SINGLE PROTOTYPE ! HOLISTIC !

Several touchpoints are tested at the same time. !

Single artefacts or interactions !

We observe interaction with

touchpoint !

We observe emerging human

behavioral patterns

PROBLEM: OVERCROWDING IN THE ED!

Crowding occurs when no inpatient beds are available in the hospital. Over time it can lead to stressful environments and staff burnout, and in worst cases mortality. !

KEY ISSUES WE UNCOVERED

Unpredictable access of patients

Ambulatory as a bottleneck

Aging demographic

KEY ISSUES WE UNCOVERED

Unpredictable access of patients

Ambulatory as a bottleneck

Aging demographic

SOLUTION IN A NUTSHELL

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Vertical (Experimental Zone) !

Horizontal (Critical care area) !

SOLUTION IN A NUTSHELL

SERVICE OUTCOMES!

Increase in amount of patients !

Percentage of patients satisfied with their

experience!Average waiting time

reduction (of low complexity patients) !

Average length of stay time reduction ( of low

complexity patients) !

186 patients!

206 patients!

75.35 min!

120.4 min!

164 min!

211.15 !

38% !

22% !10% !

RESEARCH AND DESIGN

ARCISPEDALE SANTA MARIA NUOVA (REGGIO EMILIA)!

70,000+ Patients a year!

ARCISPEDALE SANTA MARIA NUOVA (REGGIO EMILIA)!Last restructured in 1990’s One of the first hospitals to have triage in Italy!

KEY ISSUES WITH THE ASMN EMERGENCY DEPARTMENT

‘Old’ non flexible structure that creates a lot of ‘dead time’.

Increasing waiting time, and patients

Burnout amongst staff especially amongst the nurses.

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STAKEHOLDERS

UNIMORE Facilitators (Service designer + Management engineer)

15 person working group (composed of nurses, doctors and management of varying seniorities)

100+ staff of the emergency department (doctors, nurses, aid nurses)

Internal Stakeholders (Hospital administration, engineering department)

Emergency department patients (totalling about 70,000 a year)

PROJECT PROCESS Redefine the

problem !

Need finding and benchmarking!

Brainstorming!

Test!

Prototyping!

Client onboard from the very beginning that we design with prototypes, understanding it as a nessecary step

ETHNOGRAPHIC AND SECONDARY RESEARCH

Our research took place over a period of 4 months with the aim of understanding the ‘human’ needs and included: •  70+ hours of direct observation

•  14+ interviews with internal stakeholders

•  5 patients interviews

•  Extensive comparative analysis of similar cases.

ORGANIZATIONAL RESEARCH!

“As doctors sometimes we don’t even know who else was on shift

with you.”

“Sometimes there is this pressing by older nurses even

when it's not necessary”

PATIENT CENTERED RESEARCH!

“I felt as if they were cold to me, they saw me crying and did

nothing.”

KEY NEEDS

Know whats happening around you Lack of collaboration between doctors

Maintain concentration. High number of low acuity patients make it difficult for triage nurses to concentrate

Feel taken care of (Patients) Anxiety and distress caused by lack of staff /patient contact

CO-CREATION WORKSHOP!

PROTOTYPES

Area for low complexity patients An open space with the staff and waiting patients in the same room

Family room Room dedicated to family members while patients are treated

Process nurse A nurse that looks over the entire ED and manages internal flow.

DESIGNING THE PROTOTYPE

DESIGN PHASES

Scenario building Creating a base service experience to build from

Co-design and planning Working with internal and external stakeholders to define the service and data anlysis to determine its size.

Departmental communication Communicating to gather feedback, buy-in and manage expectations

SCENARIO BUILDING!

BENCHMARKING

A Better A&E by Lloyd Peterson

Rapid Assessment Zone by the Jewish General Hospital Montreal

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a & e!

CODESIGN AND PLANNING (INTERNAL)!

FINAL CONCEPT

Open space ambulatory that places waiting patients and doctors together in a more flexible and dynamic treatment environment, reducing dead time, and giving patients a more guided process.

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Features: • 2 Doctor nurse teams instead of one’ • Comfortable waiting area for those waiting for exams or simple treatment • A ‘kanban’ process making it easier for doctors to track and see patients.

FINAL CONCEPT

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DISCHARGE PHASE

Where patients would wait as they were awaiting discharge.!

TREATMENT AND EXAM PHASE

Where patients would wait to be seen by the doctor !

DOCTOR VISITING PHASE:

Where patients would wait to be seen by the doctor !

FASE 1FASE 2FASE 3

Area di presain carico del paziente e visita

Area di eventuale trattamento e attesa risultati diagnostici

Area di dimissione

SOLUTION TO BE TESTED

!

INTERNAL COMMUNICATION!

EXTERNAL COMMUNICATION!

PATIENT-CENTERED INFORMATION

EVALUATIVE PROTOTYPING DECISIONS

HOW ARE WE GOING TO TEST OUR PROTOTYPE?

PROBLEMS INHERENT WITH SERVICE DESIGN

Intangibility of services as design material

Inconsistency in service delivery

Authenticity of behaviours and contexts

Validity of the evaluation environment

Conceptualising Prototypes in Service Design, Blomkvist, 2010

We converted the old waiting area into…

Phase 1 Phase 2

PHASES IN REALITY

How to run the holistic testing, today?

READY TO START TESTING

LIVE PROTOTYPING

HOW TO RUN HOLISTIC PROTOTYPE TODAY?

!

The objective was to test whether this solution would shorten the Length of Stay and the Waiting Time, while providing a comfortable solution for patients and staff. At the same time, we needed to adjust the prototype to the needs that emerged while testing this new solution. We settled on a 5 week long continuous testing (22nd April - 31st May 2015).

LIVE PROTOTYPE AS AN ITERATIVE CYCLE

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Observation!

Weekly meetings !

Changes communicated!

We planned a feedback strategy to be able to understand all issues and emerging practices that arose during the testing, adjusting the prototype accordingly.

LIVE PROTOTYPE WEEK BY WEEK

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•  We identified eventual critical disrupted elements

•  General Impressions!OBS

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Week 1!

We adjusted the elements that could make the

experiment fail!

WEEK 1: CRITICAL ELEMENTS Doctors try to hide themselves behind dividers or columns. We reposition the dividers inside triage.


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•  Identified additional critical points

•  First ‘hacks’ emerge as well as common behaviours!O

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Week 1! Week 2!

We adjust the smallest critical points

We support or suppress the hacks or

behaviours that emerged !


•  General Impressions!


experiment fail!

WEEK 2: FIRST HACKS “More than rarely we need the patient to be undressed. One visiting box is not enough: we need two boxes for the area.”

WEEK 2: FIRST HACKS Creating new tools

WEEK 2: DIALOGUE Shared responsibility putting effort on doctors as much as nurses

“After awhile staying up on your feet all day is tiring.” – Doctor

“My legs are a lot more relaxed now that I don’t have to walk back

and forth all day.” - Nurse

WEEK 2: DIALOGUE Limit complaining, more open dialogue

“It’s a lot easier now to ask for advice and collaborate with my collegues.” - Doctor


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Week 1! Week 2! Week 3!

We suggest eventual best practices!


•  First ‘hacks’ emerge as well as common behaviours!







experiment fail!

•  After getting used to the new service, the first improvement suggestions emerge

•  Shared best practices emerge.

•  First data analysis!

WEEK 3: DOCTOR TO PATIENT Emerging best practice: Save time and deliver better feedback if you go directly to patients.

WEEK 3: SPACE CHANGES Common behavior. “There’s no need for phase 3” & We start sharing the first data results


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•  Smaller changes implemented

•  Data is analyzed!OBS

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Week 1! Week 2! Week 3! Week 4!

Live prototype closed and learnings applied!

•  After getting used to the new service, the first improvement suggestions emerge

•  Best practices emerge. •  First service data

collected !

We suggest eventual best practices!


•  First ‘hacks’ emerge as well as common behaviours!







experiment fail!

WEEK 4 & 5: NOISE Attempt to reduce noise levels

FINAL PRESENTATION TO DEPARTMENT AFTER

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1.  Showed the results, with photos and documentation.

2.  Shared an updated blueprint from the engineering department

3.  Got final feedback from everyone, with shared decisions.

OUR RESULTS AFTER 5 WEEKS

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Stop the experiment due to its temporary nature the noise levels were too high, requiring the need for final structural implementation. Lowered waiting time and length of stay overall while increasing patient satisfaction. Implemented more private spaces (boxes) into the final blueprint of the space – potentially saving thousands of dollars in restructuring costs.

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CONCLUSION

OUR LIVE PROTOTYPING PRINCIPLES

Intangibility of services as design material à Experience prototyping, role playing, design games, … were not enough

Inconsistency in service delivery à Feedback from 150 employees, with very different expertise and capabilities

Authenticity of behaviours and contexts. à How can I gain authentic feedback notwithstanding the fact it is a prototype?

Validity of the evaluation environment. à How can we ensure the prototype recreates real world conditions?

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Inconsistency in service delivery.

Testing parts is not like testing holistically.

Conceive your prototyping as a learning experience for the organisation (and for you !), not as a material artefact.


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Don’t get scared if you see the organization losing part of its competences in the first weeks, and be ready to restore them.


“In bananas” - The first 2 weeks are the most expensive in terms of energy and stress.”


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Be ready to reassure users that new behaviors could emerge and, if needed, they will be structured and officialised.



“I can’t manage to stay behind everything, including the teams.”

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How can I gain feedback from 110 employees, considering that everyone of them is going to change his mind at least twice while he experiences the prototype, and that the prototype is lively changing?


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Identify your Networking Angels (NA),

•  NAs are from your the groups that participated into the design process, because they need to know why design choices were made as they are

•  NAs need to cover each profession, so that doctors can answer to doctors, nurses to nurses, aid nurses to aid nurses.

•  Among each professional cathegory, you need to have at least a senior professional.

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Coach your Networking Angels. Those actors are your referents on the field, and answer to colleagues’ questions/feedbacks (sometimes aggressive questioning!).

•  Prepare them to: Encourage, receive and look for positive feedback

•  Bring the general perspective: Explain ‘why’ some choices were made

•  Support them, they put their face in the project and are going to be overloaded by expectations “No, listen, I am going to have a heart attack !” !


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Authenticity of behaviours and contexts.

Choose a testing length so that:

•  Everyone can test it at least 3 times “Until, it’s a one week simulation that’s ok, but I won’t accept that forever”

•  You gain data significance “Two weeks are not enough”


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Authenticity of behaviours and contexts.

•  Make the decisional process on the prototype as transparent as possible. It has to be clear to the whole organization why changes in the prototypes are made.

•  Live test in a safe and ordered way. The entire staff has to know how and who to contact in case of questions for change, and weekly report are disclosed to everybody and summarized by Networking Angels.


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Validity of the evaluation environment.

The validity of the prototypes depends on how similar the test and implementation contexts are.


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Validity of the evaluation environment.

Do not surrender to short cuts to make your testing life easier:

•  Do not change shifts to include only the smartest people during the test. We asked for extra time of an expert staff to help in case of coaching.

•  Do not ask for extra resources or only put the smartest people to test the prototype if you are not sure you are going to have them

•  Do not let assumptions derail testing. “This is not a very big town, people want to decide, relatives will never accept to be divided


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THANK YOU!

[email protected], [email protected], [email protected]

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