Nowadays, health systems are facing significant societal and organizational challenges that require enhancing their resilience and sustainability. The impressive increase of noncommunicable diseases and long-term care is accelerating the ongoing transition towards a major reorganization of the health systems. A paradigm shift is required to re-balance the relations between health stakeholders: people have to play an active role in their care, changing their behaviors for preventing and managing diseases. We are moving from a provider-led perspective to patient-centered care. This transition is both delicate and complex and demands a holistic and interdisciplinary approach to design products and services that will be used by new caregivers (patients) in new environments (home care). Besides technical and medical innovation, it is crucial to identify the actual needs of people to make them able to understand and use these new products and services. Usability, utility, and acceptability are key criteria to enhance self-care and help patients to cope with the complexity of health care. The approach of design thinking to manage user-focused problems is attracting interest in healthcare stakeholders. Design tools and methods are perceived as useful and valid to bring innovative products and services in health care, starting from the social, cultural, and operational needs of users.
At the same time, health systems are struggling to recover from the global crisis, and the need for reducing hospital expenditure is still current: this profoundly affects the innovation processes in the health sector. Economic benefits are an essential feature of all new products and services. The innovation in self-care and e-Health has positive economic implications, but it alone is not enough to ensure economic sustainability. Health systems are endeavoring to optimize processes, resources, and supplies, also driven by the increasing attention to their environmental. The health care sector is, indeed, responsible for significant environmental impacts, which often represent big economic problems too: waste production and medical infectious waste, use of chemicals and disposable materials, pharmaceuticals in the environment, radioactive pollution, etc.
Therefore, the interest in what is called “Sustainable Healthcare” has grown sharply in recent years: although in a fragmented manner, European countries are promoting new strategies in the field of Sustainable Healthcare, encouraged by international organizations which bring together hospitals, patient associations, companies and other health stakeholders. There is no common definition of Sustainable Healthcare, but all the approaches to this topic focus on making health care environmentally, economically and socially viable. To date, policy and education research are the domains that have most addressed Sustainable Healthcare, investigating the implementation of policies and actions to foster sustainability, as well as the promotion of education programs to encourage sustainable behaviors in healthcare practice. Although design could successfully address some crucial environmental issues of health care (from waste reduction to resource optimization), design research made almost no contribution to this field. The present work aims at investigating the role of design towards Sustainable Healthcare, to propose, through case study experience, a systemic vision of the topic. Specifically, we addressed the environmental issues of chronic hemodialysis, a life-saving treatment for people with chronic kidney disease. Hemodialysis has a high impact on the environment: each session uses large amounts of water and energy and produces an enormous quantity of ordinary and infectious waste. All these problems must be addressed from a system perspective since they involve products, equipment, and users, as well as the hospital system itself.
When dealing with medical treatments, we must face big challenges because of the technical and operational complexity, that is further complicated by strict and multi-level regulations. Moreover, several users interact with the system, and design has to meet all their direct and indirect needs, to provide them a safe and positive care experience. So, how can design address environmental sustainability in such a complex system, while maintaining the focus on patient empowerment and user-centered care? Traditional design approaches cannot tackle the complexity of healthcare alone, dealing with all aspects of economic, social, and environmental sustainability. A holistic approach is needed to envision eco-innovative treatment systems. Systemic Design integrates systems thinking and human-centered design methodologies to support designers working on complex design projects in multi-stakeholder and multi-environment systems. Systemic Design defines the material and cognitive flows characterizing the primary system, and thus it allows to establish new connections between the users and the contexts they are immersed in.
The first step, in our case study, was the definition of all the items which make up the system, and the users that directly or indirectly interact with them (Figure 1). We found four items that represent four levels of the system: products (packaging, disposables, devices), equipment (dialysis machine), treatment (hemodialysis as a whole) and local environment (policy and management strategies). The second step is to establish the correct methods to use: we combined different approaches borrowed from sustainable design and human-centered design to analyze each item (Figure 2). A qualitative-quantitative methodology has been used for analyzing packaging and product. It is a proven and field-tested method developed by the Politecnico di Torino, within the Observatory of Eco-Pack. The equipment has been assessed through a disassembly analysis based on Design for Disassembly, that aims at evaluating usability, accessibility and component layout in relation to the final shape. If products and equipment are designed for the world market, the treatment and the organizational strategies are very variable depending on the country, the region and the hospital. In order to establish a general framework, we compared three different dialysis units and hospitals, in three different countries (Italy, Sweden, Denmark). A specific routine analysis has been set out to assess task types, staff interaction, and patient empowerment. Finally, the local environments have been analyzed by defining the tasks and goals of each stakeholder (region, hospital, unit, home) and the relative decision-making power on environmental strategies. This comprehensive analysis allowed us to set specific guidelines for each item, taking into account technical, operational, social and environmental requirements. The organizational analysis provided us a comprehensive overview of which policies and strategies are being implemented towards sustainability and how they are affecting the other items. Overall, a systemic approach to hemodialysis allowed us to set out specific guidelines for all the items included in the system, considering the needs of direct and indirect users. The comparison of three international case studies highlighted how design must work on product and equipment to improve environmental sustainability on a global scale while addressing local systems and their specific needs to improve sustainability on a local level.
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