Innovation in service design is slow, even in Germany - Anke Holst
Before moving to Rostock, I worked in innovation in the UK, ensuring the delivery of human-scale public services. I provided strategy advice to organisations, training to public servants, and consultancy and a lot of cheerleading to public service leaders getting to grips with what was recognised as the new culture. My specialism was personal engagement with service users.
What I do now is far less cutting edge: I care for my daughter, who is being treated by our amazing university clinic medical centre. She had acute lymphoblastic leukaemia, requiring a stem cell transplant and is now being treated for graft-versus-host disease – the new immune system rejects the body.
I knew this was going to be a long and difficult journey. I involved myself in her care from the beginning, even though my daughter was just old enough to be admitted to the regular ward rather than the children’s clinic. We had moved to Rostock from a different culture only a year before and I wanted to be there for her, as well as to ensure effective communication.
In the over three hundred days we spent on the various wards, I saw an organisation where a lot of academic innovation happens, but where medical staff work in a rigid structure that does not allow – much less invite – innovation in service delivery.
This journey led me to research how the generally well-regarded German healthcare sector handles the organisational changes required to continuously develop and implement technological solutions.
In the clinic, I assumed that the current processes of transformation would have affected everyone on all levels by now, so I tried to chat to our doctors about it, out of interest and to build a more mutual relationship. When the answer was “we don’t do that here”, I tried to talk to our department leader. Somebody must be aware of and interested in something happening? Still no result. So I tried to find a relevant person in a leadership position to talk to. Rostock University, which is connected to the university medical centre, has a Chief Digital Officer, but she could not tell me who was responsible for ‘digital transformation’ at the clinic. Mails to the clinic leadership went unanswered. I was only a family carer. It was difficult explaining what I had already done professionally. While most Rostockers have heard of ‘influencers’, not many recognise what “public sector engagement” means.
I looked further afield and found that innovation in healthcare focuses primarily on new technology. Germany’s 2019 Digital Care law notes the need to move organisations on from being “not sufficiently adaptive and agile”, but does not expand on what “adaptive and agile” looks like.
I asked the supplier of the new “Telematikinfrastruktur”, a huge network connecting all healthcare providers, if they were going to use this opportunity to help people collaborate better. The supplier replied that “we trust physicians to figure this out for themselves, because they are intelligent people.” Former clinic leader and now one of the rare German service design evangelists Birgit Wezel says “new hospital software is nice, but no solution.”
The recent Future of Hospitals law (Krankenhauszukunftsgesetz) provides 3 billion Euro for hospital modernisation, but no guidance on how to make an organisation more conducive to innovation. The health ministry’s “Health Innovation Hub” focuses on electronic health records, interoperability and data formats, digital and AI applications, data donation and e-prescription. Nothing about organisations.
The federal “Association Digital Care” (Bündnis Digitalisierung in der Pflege), in its position paper on the digital transformation of hospitals, calls for more “digital competencies” for everyone. The only named competency, however, are change management skills for care staff, placing the onus for bringing about organisational change on people who are already working too hard and having the most trouble being heard.
In all German sectors, we see vague terminology used to describe what’s different now. Since moving to Germany, I have looked for where Industrie 4.0, Arbeit (Work) 4.0, Medizin 2.0, “New Work”, even “Digitalisierung” find their exact definitions and found none. But work is getting more complex for all of us and requires a different quality of collaboration. We all need to do things differently. Rather than agreeing on a set of standards, we seem to form separate and competing communities around single issues and charismatic leaders who promise relief from the pain, like John Stepper and his 12-week Working Out Loud programme.
Meanwhile, Service Design, a precise, scientific “operating system” for making innovation work, is mostly absent from the discussion. Elsewhere, it forms the basis of how things are done quickly and efficiently. Recently, the fast turnaround on the UK’s National Booking Service for Covid-19 vaccinations was the result of the close cooperation between the Lead Service Designer at NHS Digital, Emma Parnell, and the Technical Architect, Rob Sinclair – and both are happy to talk about it.
Where Service Design Thinking forms the basis of operations, problems in all parts of an organisation, including at the front line, are systematically addressed in a safe, supportive environment. The way in which traditional, hierarchical organisations work stands in stark contrast to this. The attributes needed for moving up the ranks mean that problems are rarely talked about in a constructive setting. Career advancement becomes the only way of improving things, at least for oneself, and to advance, you mustn’t complain. In my personal journey through the clinic, I became just another one of those unsolvable problems, even though I was right there, human and full of trust, willing and eager to chat, listen and learn.
Too big to change?
I suffered months of feeling like I was failing at my job of caring, and uncharacteristically also failed at finding anyone to talk to about it. The psycho-oncologists were great, but I needed help to do my work, to fit into the big machinery. When I slowly stopped blaming myself for everything going wrong, I asked a group of nurses in the hallway what caused them more stress, their work with patients or “the organisation.” The answer came as a shock, knowing the work these specialist nurses are doing every day, caring for patients who are undergoing the most extreme medical interventions in an effort to save their lives. What caused the most stress was “the organisation.”
Yet asking what might be done about it was seen as behaviour aberrant enough to require therapy. I looked for signs of enthusiasm about the possibilities: complex health data visualised on devices rather than stuck in large paper files, or implementing collaboration methods so knowledge would flow to where it was needed.
On a journey back from a week of radiotherapy in a different city, I managed to chat to a young doctor for long enough for him to tell me that he did indeed have ideas for how things could be improved. But that remained the only time.
When I asked local technology suppliers for support in bringing awareness of the existence of service design to the clinic leadership, I was asked “… why try to do impossible things, when there are easier ways to earn money in IT?” In a free market there won’t be supply without demand, so there aren’t any service design agencies in Mecklenburg-Western Pomerania. In other parts of Germany groups drive interest in the subject, but they have no presence in our state.
Like many other healthcare organisations, ours is an long-established university hospital, full of idealistic, wonderful, intelligent people, proud of its history, but with deep divides along political, departmental, hierarchical and even gender lines that work against any efforts to change it for the better.
- How change is supported elsewhere, despite similar challenges
Service design projects are happening in some German hospitals: a Munich accident and emergency department used service design principles to improve processes in patient admission. There are specialist agencies in both Berlin and Hamburg. The Health Innovation Centre of southern Denmark states Service Design as one of their supported areas of expertise, and most of their published content is available in English.
In the UK, where I spent my formative years in public sector innovation, we met in participative event formats that formed a culture of doing things better, together. In 2010 I proposed and organised the London #localgovcamp – the following year the UK Government Digital Service was announced at #ukgovcamp. A ‘barcamp’ or ‘unconference’ has a theme, but no prepared agenda. The session plan is assembled at the start of the event from the suggestions of the participants. There are talks in break-out rooms and attendees get to actively participate.
The result was an open, collaborative, innovative culture. People making themselves available and forming lasting connections. Institutions aren’t faceless anymore, but made up of approachable, enthusiastic individuals. Innovation is not something other people are doing elsewhere, out of our reach, but something we are involved in and can grasp.
Communication, talking about what we do, and collaboration, working with others, is part of the day job for knowledge workers. Blogs form the public face of both the GDS and NHSX, the organisation driving digital transformation in the UK’s National Health Service.
The values and principles underpinning their work are presented and communicated openly. Jeremy Gould, deputy director at Defence Digital Transformation, describes “The [GDS] service manual, the design prototyping toolkit, the design principles, the tech code and the service standard are … codifications of good practice developed over a long period of time and contributed to by many experts. Collectively they represent a significant body of experience about how to build better user centred public services.”
A group of lecturers from universities around the world, including Professor David Eaves from Harvard and Professor Ines Mergel from Konstanz University, recently started “Teaching Public Service in the Digital Age”, enabling the development of competencies around Service Design in public service leaders. The teaching materials, as well as the above mentioned codes, principles and manuals, are free and open to be used by anyone.
- What service design project delivery could look like in our clinic
There are predictable issues when introducing changes to an organisation and the more experienced agencies in this space include psychologists on their teams. The more the organisation has resisted change so far, the more frightening the initial responses can be. Actively dealing with difficult emotions is a part of the process. Creating psychologically safe spaces where people can say things that would have previously hurt their careers takes conscious effort.
Leaders need to lead by example and visibly support this process by being emotionally present. Trust needs to be built where it has not previously existed. Empathy now has a role to play where it may before have been an obstacle. There is patience we need to have with ourselves and others. There are relationships we may need to rebuild. There are changes in us as we respond to changes around us. As we start seeing our problems as deserving of a solution, we will begin to see our work in a different light.
The introduction of service design is a change process, and change can be a challenge. It can be very emotional. I remember how I responded the first time my emotional life was taken seriously after a difficult time. A proactive approach to this in a clinic setting could be the collaboration with one of the psychotherapists from the organisation. They have listened to the problems for a long time, some of them are ready to be part of the solution.
The process of service design is not standardised and doesn’t necessarily follow a set path. In this setting, a project could look like this:
Exploratory User Research
The first principle of service design is to start from user needs. A user is everyone who is affected by how a process works – not just the patient. The facilitator would encourage a diverse group, including members of all the occupational groups, to look at their pain points. Facilitating these conversations requires skill. Usually, the people doing the work already have ideas for solutions: this is where they can, sometimes for the first time, be heard.
The pain points collected in these first sessions will be analysed and an agreement will be reached which ones should be addressed in this project. Because this is a continuous cycle, other issues are deemed just as valid and kept for another time.
Depending on the nature of the pain points, specialists will be invited to support the ideation process with knowledge of what is technically possible. For example: the problem may be communication and may call for the introduction of a new platform.
The experts collaborate with the team on a design of the new processes. If new technology is introduced, we consider who uses what, when and how.
The new process is tested in a limited setting. Because of the involvement of the team, this happens at an earlier stage than during other project management processes.
With the feedback of the users, the solution is being continually improved and is now implemented at a larger scale.
This feedback continues to flow and continues to inform the work of the service design team. Everyone who works in the organisation, even if they haven’t been involved in the exploratory sessions, should know that their feedback is a welcome part of the change process.
There are various approaches to applying service design. Public sector organisations may establish an in-house team. Specialist agencies exist, but their involvement is usually time-limited, where a long process of gaining trust and building competencies may create more sustainable results. There is no ideal solution, since much depends on the organisation.
With technology, we can now listen to the experience of individual service users. Without direct engagement, where managers represent staff – but where staff aren’t open with their managers – innovation is impeded.
Developing an innovative culture is a journey. Taking the first step does not necessitate expensive consultancy, but it does require new thinking and competencies in leadership. Organisational culture is a living thing: giving it a different direction should not require forcing or breaking things.
“Too much information, complexity, changing conditions? Time for learning! Your existing tools, methods and processes might not work in this new environment. Be curious and listen to your people. The know-how is out there … if you ask.” – Harald Schirmer, manager for Digital Transformation and Change at Continental AG.
As for my story – we are still in the middle of the journey, but this is the end of a particularly difficult chapter. An environment can feel hostile, even where each individual has a heart of gold and the best intentions. Looking at the structures and long-held convictions underpinning it all has been more therapeutic than any rehab – and easier to do during a pandemic.
Links and illustrations: https://ankeholst.com/uniklinik/