Holistic Outcome-Based Approach towards Sustainable Design Healthcare: Aligning the system purpose through system visualisation

Authors: Landa-Avila I. Cecilia, Jun Gyuchan Thomas, Cain Rebecca, Escobar-Tello Carolina

Healthcare outcomes
Systems thinking
System visualisation
Boundary object
Design method
Sustainable healthcare

Long-term conditions represent a healthcare crisis that requires a holistic and sustainable intervention. Systems thinking is fast becoming a vital and suitable approach to face the complexity of chronic care design and development. Systems thinking is considered a reasonable approach to cope with value conflicts between stakeholders and to generate consensus through the negotiation of the different healthcare systems elements. Although there are models that support the implementation of the system approach, there is still little understanding about how to assist the tension of conflict of values and purposes across the different stakeholders.

For example, even if the overarching goal of healthcare such as “achieving people’s health” seems a well-established consensus among the healthcare stakeholders, the broad interpretation of the different stakeholders could generate diverse proposals of how to address it. These discrepancies can cause processes of change towards sustainable healthcare systems to be hindered and fail in their implementation. Therefore, to negotiate the purpose of the system is a critical action that should occur in the early stages of the project and it should be carried by participatory encounters.

However, the participatory encounters in healthcare face challenges such as the lack of a common language, busy schedules, lack of empathy for the needs of others and low understanding of complex systems. Thus, strategies to trigger understanding and help to deal with value conflicts among communities of practice towards the definition of system purpose needs to be explored. Among promising strategies there are visualisations. Historically, visualisations have helped to address the discussion of complex topics and to generate models to interpret the interaction of complex systems.

Although a system visualisation facilitation method can be used to facilitate the collaboration to make sense and to co-create a common understanding of the system among different stakeholders, this technique requires support elements that guide participants during the process. A holistic outcome-based approach has been proposed in an attempt to carry out the process to facilitate a system visualisation method.
Outcomes are commonly present in healthcare systems and normally are linked with the aim and objectives of the stakeholders. However, outcomes have been barely explored as the main element to represent systems. Then, outcomes are an opportunity to negotiate the system purpose through participatory encounters; but, at the same time, outcomes will offer elements to guide and to link the stakeholders with a broader perspective of the system. This outcome negotiation process should be a participatory method able to facilitate the systemic thinking, the empathy toward the relevance of other stakeholder needs and outcomes and, finally, to allow the identification of a potential strategy to align the actions of the stakeholders towards the system purpose in a sustainable manner.

The first proposal of an outcome-based system visualisation technique was generated following a literature review. The most relevant healthcare outcomes included were traditional outcomes such as biometrics, health-related behaviours, safety and quality of care. In addition, novel meaningful outcomes such as subjective wellbeing and happiness were identified as potential leverage across the system and therefore included to complete the holistic outcome.

This paper attempts to explore how to visualise complex systems interactions using a holistic outcome-based approach.
A three-hour workshop was carried at a major design conference to generate system visualisations. The workshop was firstly adapted following recommendations from Sevaldson and Jones and Bowes. However, there were adjustments made after the pilot; the corrections were mostly to clarify the instructions of each task, adjust the time of each phase, and to remove the evaluation of an author visualisation.
Participants of the final workshop were recruited by invitation of the conference organisers. They had access to a description of the workshop prior to signing in. Although previous experience in healthcare systems was not mandatory at least 80 per cent of the participants expressed to have some type of experience in the design of healthcare services.

23 participants worked in 5 teams facing three main tasks. First, to generate an individual visualisation; second, to propose a team visualisation using outcomes, and finally, the teams produced narratives to orally explain their visualisation.
Overall, the data consist of twenty-three individual visualisations and five group visualisations with their narratives. The visualisations were analysed and compared to find relevant patterns across the teams.
The results of the visualisations suggest that there is not a clear visual pattern to make sense of systems through outcomes. Although, some outcomes, such as the psychosocial were more present in the visualisation as a link to the patient, the clinical outcomes were mostly associated with the healthcare system.
However, one of the main remarkable situations is how the visualisation technique and the use of outcomes triggered and encouraged open and meaningful discussions among the participants. Outcomes were an element to work around that guide and help participants to deal with a smaller subsystem.

These findings can suggest that outcome-based systems visualisation is a promising method to trigger meaningful discussions, increase the awareness of the systems elements through a holistic vision of what it is relevant for the different stakeholders. Nevertheless, these conclusions may be somewhat limited by the inclusion only of participants with a design knowledge. However, these findings gathered important feedback for developing further systems visualisation methods that pretend to include patients, family, and the wider interested community. A further study with a focus on the use of an outcome-based visualisation as a participatory approach that includes patients and providers is therefore suggested.


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Presentation & paper

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Author(s) (20XX). Article title. Proceedings of Relating Systems Thinking and Design (RSDX) Symposium.