Service design in the healthcare space with a special focus on non-clinical service departments: A synthesis and future directions

Abstract

Although there has been a tremendous change in the way diseases are diagnosed and treated, the ways in which health care delivery has been managed has seen very little change.

Several academic studies have arisen in the area of service design, but an amalgamation of this research, especially in the area of healthcare services is not available. The aim of this systematic review is to evaluate the published research on service design in healthcare and accordingly identify the gaps and scope of future research. After analyzing the articles and reviewing the Service design in healthcare literature, the following are our main contributions: (i) clarification of the service design concept and the developments that appears in the literature review of service design in the healthcare sector; (ii) classification of the service design tools and techniques that are most commonly used in the healthcare sector; (iii) demonstration of the service design as the preponderant construct that is used as a tool and technique to improve quality and efficiency in the healthcare service.The resultant systematic review reveals a change in the type of research carried out, the service design tools used and a shift towards service design from using the co-design tool to other methods. The paper highlights the gaps in the very limited amount of empirical work in the non-clinical healthcare space and accordingly a model is recommended.

Keywords

design thinking healthcare service design systematic review

Introduction

Although there has been a tremendous change in the way diseases are diagnosed and treated, the ways in which health care delivery has been managed has seen very little change. In difficult times like what the world is facing with the Coronavirus Pandemic and has faced in the past with other disease outbreaks, service design thinking can help ease the process in order to function more efficiently.

Service design refers to designing services so as to make the services convenient and comfortable to use. We utilize services day in and day out, in all avenues of life. A service happens over time and is made up of several customer touchpoints, where the customer comes in contact with the service.

Service design is the process of creating these touchpoints and setting the tone as to how they will be interacting with the users. Till date there is no specific definition as to what is service design. Various researchers have defined it differently. Some definitions refer to service design as everything.¹

One definition by the author Johnston R. in the year 1999 states that “In service design, we seem to have followed the blueprinting movement but we appear to have ignored the process of design in favour of this descriptive activity and the relationship between important, and often ignored, back-office activities in favour of customer-facing processes.”² While yet another author defined it as “Service design aims at designing services that are useful, usable and desirable from the user perspective, and efficient, effective and different from the provider perspective. It is a strategic approach that helps providers to develop a clear strategic positioning for their service offerings. Services are systems that involve many different influential factors, so service design takes a holistic approach in order to get an understanding of the system and the different actors within the system.”³ Another author Goldestein stated that, “.Designing service means defining an appropriate mix of physical and non-physical components.”⁴

Although the impact design has on the business success is quite well researched and available for manufacturing and product companies readily, service companies have not adopted it on a large scale as they do not see any role for the design. The service design tools can help to have an in-depth analysis of the expectations of the customers and thus would help to satisfy their needs, which could ultimately lead to the development of new support systems.⁵ Official acceptance of service design as an unmistakable disciplinary area of investigation only occurred around 1991.⁶ Service design was given more attention post this. The service Design field specialists have embraced a methodology, which involves better understanding of the clients and their needs, understanding organizations and their practices, accordingly understanding it so as to come up with solutions to the problems faced by service organizations. Thinking with models when designing complex systems, helps to resolve the matter easily.⁷

Background

Service design and its growing importance in the healthcare space

Service organisation heads have now started to look at service design and design thinking in their quest to come up with unique offerings for their customers, so as to stand out in the market. Organisations have the need to understand the aspects that are important to the end users, which can be a complex process. Service design is being utilised to make user-centric services.⁸ Given the increasing significance of service design, it is looked as a means to achieve service quality, particularly due to its purpose in creating ideal customer encounters in a service environment. In the healthcare space which includes healthcare services like diagnostics, hospitals, clinics and pharmaceutical companies optimising the outcome for the expenses is extremely important without the decrease in quality is of significant importance. Service design has shown to help healthcare organisations to ensure their functioning in an effective and efficient manner.⁹

For years together the focus of healthcare innovation has primarily been on the clinical setting which includes upgrading the medical devices, upskilling the medical personnel through CME’s(continues medical education) which is important no doubt, but with the increase in the competition and the increased needs of patients, sufficient focus needs to be paid to the non-clinical setting which involves the administration, front office, marketing department, Operations department and all the support functions that do not directly contribute to the well-being of the patients but indirectly play a role.

Some service design tools available to be implemented

Below are some definitions of some appropriate tools that are indirect in their manner of improving a service design without actively involving the patient or relatives.¹⁰ There are several tools in service design, only some of which are explained here.

Empathy map

The empathy map is a canvas, split into four quadrants (says, thinks, does, and feels), all positioned around the user. Filling the map allows to produce an overview of who the user is, and to identify inconsistencies in the perception of the same user from various team members (and so intervene to mitigate the conflict).¹¹

Persona

A persona is a model of reference describing a particular behaviour of the users. They concentrate on identifying the different behaviors without displaying a specific personality and thus they can be referred to as behavioral archetypes. And as these so-called archetypes adapt these identities, the closer do they get to the real persona thus fully expressing the needs, desires, habits and cultural backgrounds of specific groups of users.¹⁰

A user scenario

A user scenario is a tale that explains, in an outstanding and concise manner, the most ideal way one should interact with the service in certain situation. Building user scenarios involves defining a specific context where the action is taking place, as well as protagonists and expectations that determine the real user's attitude.¹⁰

Emotional journey

The emotional journey is an extension of the usual experience journey map (or customer journey map) that associates an indication of the emotional status of the user at each stage of the experience. The emotion can be represented by a curve floating from moments of frustration to delight, or by adding emojis and pictograms to the specific steps of the journey.

Observation notes

Writing notes during observations sessions help make the most out of that research activity, making sure to capture insights as well as data concerning what’s happening around (e.g. how many times an action is repeated, how long it takes, steps covered, etc.). Preparing a dedicated support such as a printed grid or notebook with specific investigation areas to fill during the session could be valuable to guide the researcher by suggesting data points to capture, and so avoid missing out any important aspects.¹⁰

User stories

User stories are a tactic that arises from the Evolutionary technique, used to explain the characteristics of a service from a user perspective. The user stories bring in all the elements and experiences that the user envisaged and thus helps to co-relate to the design team's work and bring out a better flow in the work.

Directions in service design research

Over the last 20 years, service Design has become a tool to bring about innovations in the service domain. Service Design helps to create meaningful experiences and improves efficiency, which is what sets organisations apart. It is inspired by user-centred design, emotional design, design thinking, and contextual design. The experience centred method utilises the experiences faced by the users as a basis when creating innovations and changes to the services.

Methodology

This systematic review is focussed on service design in the healthcare domain. The authors have a set of research questions that they expected to answer through this study:

RQ1: What is the scope of service design work and the developments that appears in the literature review of service design in the healthcare sector over the years?

RQ2: What are the the service design tools and techniques that are most commonly used in the healthcare sector?

RQ3: How is service design as the preponderant construct, used as a tool and technique to improve quality and efficiency in the healthcare service?

The research was a systematic review of the literature and looked for a comprehensive method that was replicable (Table 1). The idea behind this study was to analyse the scale of the implementation of healthcare service design and accordingly to come up with a relevant model for the non-clinical healthcare settings. Authors included only peer-reviewed journals and excluded book chapters, conference proceedings etc. Peer-reviewed journals are an assurance of certain level of quality and hence has been used as a criterion. 3 electronic databases the EBSCO, Google Scholar and JSTOR were scanned thoroughly to get the appropriate papers (See Figure 1).

Data gathering

After examining the relevant publications, data was gathered from those 58 publications. The authors began by recording basic details about the publications: title, author(s), journal name, year of publication, system of service design used, whether the work was in the clinical or non-clinical setting. The two main fields of interest in this paper were service design and healthcare with a focus on the Non-clinical Setting after gathering the basic information.

The papers were examined and the gathered information was then arranged systematically.

Result & analysis

Summary results of studies directly testing service design methodology in healthcare

The role of service design has become meaningful, as it helps organizations to look at the larger picture. Service design includes tools and methods for improving existing facilities or creating new ones. The service design approach, enabled by approaches and resources, executives, administrators and policy-makers will work collaboratively to build desired futures. While many healthcare organisations engage in service design as a means of realizing new services, service design also entails multi-level transition, because service includes the organisation, its staff and consumers ultimately.^12,13 As such, there is a growing awareness of how service design affects the environments where it is used by means of its methods and approaches. Service design is particularly seen in clinical settings as a means of including patients and their experiences in the development process, and seeking to hear the voices of patients and their family members. These goals and the resulting participatory mechanism are demonstrated by the use of experience-based codesign, used by the NHS(National Health Services, UK) among others, to ensure the participation of stakeholders in enhancing and redesigning health care processes.¹⁴ A hospital where drama and participatory methods were used to promote the continuing prototyping of a new environment was a very interesting case. This method used the simulation techniques to discuss possible futures with the hospital ward's various stakeholders, which worked well for the hospital.¹⁵ To sum up, service design provides a creative approach to promote healthcare change through cooperative and participatory strategies that leads to creating experiences that are meaningful and appreciated and the needs of the patients or the healthcare consumers are met.

When analysing the methods of studies used by these 58 papers, it has been found that majority of the studies followed the case study approach, almost 70% of the studies were in this category and the rest of the studies were conceptual papers. There were only 4 studies that were empirical studies, which showed a stark lack of empirical research focus in this area.

When the years 2016–2019 studies were reviewed, 23 out of the 57 records belonged to those years itself. This illustrates the overemphasis of healthcare service design. In one study, the service design helped create new beginnings by increasing and improving communications, getting access to knowledge acquisition, between a pregnant woman during delivery and the healthcare providers and other family members, in a maternal and new-born health centre in Uganda and Nigeria. These interventions resulted in an increased satisfaction amongst the patients as well as healthcare workers, which ultimately affects the hospital in a positive manner. Yet another study spoke about utilising evidence based and experience-based models so as to create a system wherein one can predict the risks associated with the progression of diseases and thus creating a healthcare environment that is insight based and evidence based, which makes the diagnosis accurate.¹⁶ Another very interesting study pointed out the effectiveness of designing for safety, the study was conducted for the NHS using journey mapping and the process was focussed on understanding which interface framework were the most successful.¹⁷

Focus departments studied

The first step in the review was to look into the features of the basic sample. The subject areas listed in this analysis are summarized in Table 2. The highest number of Service design studies in the clinical segment was found in the department of Mental health (n = 8), followed by service design application to Public Health (n = 7), and then Emergency Department (n = 6). When looking at the above chart, it points out that the highest number of cases in the non-clinical section are in the General area and not specific to any particular department, this is then followed by public health for non-clinical or administration related studies.

Table 1.

Summary of the selection criteria.

Types of filter	Description	Results (Google Scholar, EBSCO and JSTOR)
Considerable	The studies containing the keywords ‘Service’ and ‘Design’ in the title, keywords, or abstract	19,200
Considerable	The studies containing the keywords ‘Healthcare’ in the title, keywords or abstract	11,817
Considerable	Combine the previous results using the Boolean operator AND	6732
Duplicate	Records of duplicate research found in all the databases are excluded	957

Table 2.

Departments studied.

Department	No. of studies in each department/area
Ambulatory healthcare¹⁸	1
Cardiovascular^16,20	1
Cerebral palsy patients²⁰	1
Clinicians	1
Diabetic patients²¹	2
Drug abuse	1
Emergency department²²	6
General	9
Home care^23,24	1
Hospital acquired infections	2
ICU²⁵	1
Maternal and newborn²⁶	1
Mental health department	8
NA	4
Neonatology	1
NHS direct	1
Oncology²⁷	1
OPD²⁸	3
Organization wide	1
Orthopedic department	1
Pediatric²⁹	1
Participant communities³⁰	1
Professional care organization	1
Public health^31,32	6
Vaccine department³³	1

Table 3.

Segregation into clinical and non-clinical departments.

Department	No. of studies
Clinical	34
Non-clinical	24
Grand Total	58

The service design tools in the studies associated with the Non- Clinical setting

With the sensitive nature of the Service, and the state and frame of mind that patients usually come in when they visit the hospital, the tools that reflect in the above figure are not the most appropriate to improve the patient experience. There are several tools that are still unexplored like the Ecosystem map, Emotional journey, Empathy map, Observation notes, Personas, User Stories and User scenarios which are more indirect methods with active efforts to understand what the patient and relative actually go through. Patients and relatives are usually overwhelmed when they visit a healthcare facility. They would not want to be hassled by being a part of any service design voluntarily and hence some of the discreet tools would be more appropriate. Hence the Figure 2 Service design model points out clearly the most suitable tools that a healthcare organisation can explore when applying service design to a non-clinical department.

Figure 1.

Systematic review of service design, flow diagram of search results.

Figure 2.

Proposed service design model.

Figure 3.

Year wise categorisation of studies done in clinical and non-clinical setting.

Figure 4.

Studies done in clinical and non-clinical setting.

Discussion on the insights derived from the reviewed literature of service design in health

In this section the 3 questions that were proposed to study are discussed here based on the findings;

RQ1: What is the scope of service design work developed in the healthcare space, and what are the improvements that have taken place over the years?

In this systematic review the authors searched for relevant publications that were published over 2 decades before, to go back as early as possible, although there were a sufficiently large number of publications in the last 4–5 years (See Figure 3). The papers that were identified to be suitable after using the selection criteria were only post the year 2002. The studies in the healthcare domain started by focusing on the most popular service design tools like Co-design, Prototyping and the likes. It is only after the year 2012, that the studies have moved towards exploring the other service design tools. But at the same time there are several tools that are suitable, based on the context applied. In a healthcare setting most patients and relatives are not in the best mind frames to be a part of the process of re-designing a service. In such situations it is most favorable to use some indirect tools of service design, that do not disturb a patient or relative who are already hassled with their own issues. It was expected that in the field of public health there maybe resistance to deal with open-ended processes not having any predefined outcomes (See Figure 4). One other research pointed out that most service organizations don’t see value in using the service design concept. Empirical studies which are largely lacking would help improve the value seen by service organisations. Another aspect noticed is the journals that these papers have been published in are mostly medical journals and a very small percentage are management journals, thus calling for the scope of non-medical journals to also focus on improving the focus of looking at service design in the non-clinical or administrative aspects of hospital services (Table 3).

RQ2: What are the the service design tools and techniques that are most commonly used in the healthcare sector?

The latest trend in the research of service design indicates that in the last 5–6 years the service design applications have been explored in various departments in the Healthcare domain, including the Mental Health Department, Emergency department, Pediatric department as well as the public health domain. There has also been a move to exploring different Service design tools. Although it is predominantly the tools like co-design, prototyping, consumer engagements that are used, there is a noticeable shift towards using other tools like Journey mapping and the critical incident technique. There was this other study that showed that design thinking can bring about transformations in healthcare and sort out long standing issues through some of the service design concepts like co design and rapid prototyping.³⁴ Also another aspect noticed is that 70% of the studies are case based and around 30% of the papers are conceptual papers. There were only 4 papers that were an empirical study, showing the need of empirical studies in this area.

Co-design and prototyping have been most popularly used in the studies in non-clinical settings. These may help further studies in service design domain in healthcare and may lead to the adaptation of work to improve research related to this topic. Concepts of service design are sometimes difficult to define, and therefore the need for systematic review gives one a better sense of the gaps and the future possibilities of progress in this area. Organizations differ and so does the interpretations of service design and design thinking differ from institution to institution. It is not structured, so collecting and disseminating information on programs using these approaches could be complex. Another popular method that was found in these studies was the experience-based methods and consumer engagements.

RQ3: How is service design as the preponderant construct, used as a tool and technique to improve quality and efficiency in the healthcare service?

In the analysis of these 58 papers, the close link between service design and the improved quality in care comes out very prominently in most of the papers reviewed. When Ponsignon, Smart, & Phillips, use the critical incident technique in their study of the customer journey in healthcare they find a correlation in the dimensions of experience quality and servicedesign across the patient journey.²⁷ Similarly Salgado et al., 2017 in their research on the service concept and tools to improve maternal and new-born health in Nigeria and Uganda acknowledge that the quality of care is improved with the use of the service design tool, co-design which improves the communication during delivery between the health care provider, the woman and her relatives.²⁶ The analysis presented by Da Rosa, de Borba, Leis, & Vaccaro in 2015 demonstrate the usefulness of service design for the development of more robust solutions in the health care environment.²⁵ Service design as presented in the reviewed papers has been found to have strong linkages to improve the experience of patients which helps transform the relationship between professional care organizations and the communities they work with.^24,35

Another interesting aspect is how Freire & Sangiorgi, 2010 report on how these paradigmatic changes through service design are mirrored in public services reform.³⁶ The benefits of service design implementation are seen by all the stakeholders in the healthcare space, thus is highly appreciated.

Many findings relating to the scope of research on service design in health have been acknowledged in the process of performing this study (See. Table 4), and are summarized here.

Table 4.

Tools and techniques of service design used in the non-clinical setting of the hospitals.

Service design tools	No. of studies
Blueprinting	1
Co design	7
Consumer engagement	1
Design behaviours	1
Design games	1
Experience-based methods	3
Human centred design	1
Journey mapping	2
Prototyping	5
Prototyping, ethnography	2
Grand total	24

Conclusion and scope for future research

It is the first systematic review in the domain of healthcare service design with a general view of Healthcare and a special focus on the non-clinical setting. The results of this study would specifically benefit healthcare administrators, practitioners, service designers in the healthcare field and researchers working in the same area. In this study particularly, the gaps were identified as to where and which area in the healthcare field has not been adequately explored and has a scope for future research. Based on this, there was a proposed service design model (See Figure 2) which points out to the most suitable tools of service design especially for the non-clinical or administrative setting. This model will be very useful to healthcare managers, hospital administrators who would want to choose the tool to apply in their hospital non-clinical departments. There is a large scope for empirical research in the area which would add tremendous value. There is also future scope for service design to be applied in non-clinical areas of the hospital like housekeeping, marketing and the likes. The researchers can look at the level of satisfaction amongst the employees as well as amongst patients post application of service design tools to improve efficiency.

Hence researchers should choose some of the identified gaps for their work in order to strengthen their service and improve by testing this model for its efficiency.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nafisa Vaz

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