People often have an image in their minds of what co-design is and what it looks like. That visual is often of a creative setting with whiteboards, or perhaps in the minds of the more tech-savvy, touch screens, with silicon-valley-styled professionals debating ideas and moving objects around a mind map or user interface design on the screen. Perhaps even a small buffet of drinks and snacks somewhere in the corner of that setting. In essence, that general image is closer to something you might see around the offices of the high-flying giants of Apple, Google, or Microsoft.
Firstly, what is Co-design?
Co-design actively involves multiple stakeholders (internal and external) in the planning to improve systems and services (Alberta Health Services, 2020). It is a participatory, reflective, and adaptive process centring on participants as experts. It decentralises decision-making and power to facilitate more transformative change (Sahagun & Holley, 2018). The approach creates environments and develops solutions that are more responsive and appropriate to the needs of all stakeholders. In “true co-design” stakeholders (Alberta Health Services, 2020):
- participate, as equals, in decision-making
- are involved in all stages of the co-design process
The concept of co-design is not new. It has been around for decades, albeit in different shapes and forms, and its methodologies have evolved and even multiplied over time. It has been tried and tested in clinical settings in Australia to varying degrees of uptake and success, but has often battled the rigidity, complexity, and bureaucratic nature of the healthcare industry, not to mention resource scarcity.
Consumer involvement is at the heart of co-design. The term ‘involvement’ is often interpreted in many different ways and used interchangeably with terms like ‘consultation’, ‘participation’, ‘engagement’, ‘partnership’, ‘co-production’ and ‘collaboration’. A helpful way to think of consumer involvement is decision making with or by consumers, rather than ‘to’, ‘about’ or ‘for’ them (Ocloo and Matthews 2016).
So, what does it really look like in an Australian hospital setting?
A recent presentation at the NSW branch of the AIDH provided an insight into the opportunities, challenges, achievements, and lessons learnt of a three-year co-design journey in a multidisciplinary cancer care centre owned by the clinicians at the Sydney Adventist Hospital (commonly known as ‘The San’). A case study of the good, bad, and not-so-ugly so to speak, with the recording of the presentation accessible at AIDH Digital Health TV.
While it goes without saying that it is vital to understand and analyse what problem is being solved and who the consumers are before embarking on the solution journey itself, it is just as important to evaluate whether co-design is going to be the right approach to solve that problem and especially whether the organisation has the resources, expertise, tools, environment, and even the right culture to do so.
In the San’s example, the hospital’s Integrated Cancer Centre identified that they were dealing with a wicked problem, with the consumers in this scenario being cancer clinicians of various roles and specialities. The hospital has ten different cancer teams (structured by cancer stream: breast, lung, prostate, etc…) with at least a dozen different clinical roles (e.g. surgeons, medical oncologists, nurses, pathologists, radiologists, radiation oncologists, etc.) consulting on every patient’s care, each of whom have their own workflows and systems within their departments, and all of which is happening in a private hospital setting where clinical team members are not always on-site and technically not employees of the hospital per se.
It became quickly apparent to the organisation that no ‘off-the-shelf solution’ would magically solve all problems. This led to the consideration of a co-design approach. The approach itself presented several opportunities, a key one of which was an early intervention to change management. Given that this is a private hospital reliant on clinicians bringing their patient cases to the hospital, as well as the fact that those clinicians practice in more than one hospital as well as their own private clinics with their own systems, another new system ‘forced’ on them or one that they need to spend a lot of time learning was destined to be a change management nightmare.
A co-design approach from the ground-up
To tackle the complex circumstances, the organisation took a 4-step approach to co-designing the solution: Involve, Assign, Project, and Iterate. Firstly, involving the clinicians early in problem ownership provided them with the opportunity to present their own challenges, buy into the need to solve the organisational problem, and engage in change management right at the start of the project. This is in contrast with the traditional approach to change management being introduced later once a solution has been selected and/or implemented.
Professor Gavin Marx, the San Integrated Cancer Centre Clinical Director highlights the importance of this step concisely:
“We needed the clinicians to tell us their drivers, pain points, co-own the benefits, and provide continuous validation and process improvement as we go – otherwise they won’t have a reason to use it!”
Secondly, assigning the appropriate clinical champions of each component (in this case, cancer department/stream) to corral their own teams and represent them in the overall solution. This was a key step that helped identify which components of the solution were universal, that is common to all departments, and which components were specific to the clinical needs of each team.
Thirdly, a strong project governance structure was put in place. A project team was created with representatives from clinical, clerical, administrative, and technical personnel. Clear communication and coordination structures are key to projects that involve what may be seen as ‘too many cooks’ to ensure clear decision-making criteria and consistent project progress.
And finally, continuing to iteratively test and adapt the solution in highly iterative agile cycles allowed for immediate feedback by the clinical teams and greater stakeholder satisfaction. The importance of having a technical team and solution that can rapidly adapt is a key success factor to this step.
Putting it into practice
Putting it all into practice can be a real whirlwind. The process of co-design came in various forms in this case study. The participants had diverse approaches during the ideation stage. Some participants preferred to use their paper forms as a starting point and hinge their ideas on what they currently do, some preferred a blank slate to try and reimagine the whole process, some wanted to be given a starting point in terms of some predefined workflows and designs to comment on, and some wanted as little participation as possible.
Then, when it came to turning ideas into designs, it was rarely that Apple/Google/Microsoft environment we envisioned. In fact, unlike the scenario in innovating tech giants, for this multidisciplinary team the project had to be shoe-horned between competing demands in addition to the constraints introduced by the COVID-19 pandemic. While some face-to-face and webinar workshops were run, the mixture of methods included clinicians receiving draft screenshots and wireframes to comment on and return. Others preferred to wait until there was a test system available to do a dry run and report feedback, and some preferred communicating their ideas and feedback over the phone on the run!
A reality check
The reality is that the project team had to cater to a diverse set of preferences and roll with the punches. When involving consumers, prioritising and respecting their time and preferences are critical success factors of the co-design process. This is the reality of co-designing in a clinical environment under high pressure, limited resources, with a cocktail of pandemic-related lockdowns and isolation. And yet, despite these constraints it still achieved the desired outcomes set by the clinical leads from the outset.
In the world of co-design, perfection can indeed be the enemy of the good. It is a process that has so much reward, but it naturally leads itself to the “one more cycle” trap which can be a never-ending process towards the illusion of having the ‘perfect’ solution. The key to drawing the line is establishing a pathway for continuous process improvement post design and implementation. No matter how hard a team can try to set up the perfect solution from the start, it will always fall short when put into practice due to the nuances of subconscious clinical processes as well as the natural evolution of said processes.
If you are interested in reading further about consumer involvement, the NHRMC provides a comprehensive set of guidelines on this topic.
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Ali Besiso
Managing Director, iCIMS, & NSW Branch Committee Member
References
Alberta Health Services. (2020, January). /Understanding Co-design/. Retrieved from here.
NHMRC. (2018, Nov 23). Guidelines for Guidelines: Consumer involvement. Retrieved from here.
Ocloo, J. and Matthews, R. (2016). From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Quality & Safety 25(8): 626-632. Read more
Sahagun, A., & Holley, J. (2018, Aug 29). Networkweaver. Retrieved from The Promise of Co-Design.