GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 5, Number 2, 2016 Original Article ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2015.0091

Game Maturity Model for Health Care

Jan C. de Boer, MSc, Paul Adriani, MSc, Jan Willem van Houwelingen, MSc, and A. Geerts, MSc

Abstract

This article introduces the Game Maturity Model for the healthcare industry as an extension to the general Game Maturity Model and describes the usage by two case studies of applied health games. The Game Maturity Model for healthcare provides a practical and value-adding method to assess existing games and to determine strategic considerations for application of applied health games. Our forecast is that within 5 years the use and development of applied games will have a role in our daily lives and the way we organize health care that will be similar to the role social media has today.

Introduction problem-solving and learning. Although applied or serious games are entertaining, their main purpose is to change the aming can be seen as a next step in the application of behavior of human beings and organizations (e.g., patients, information technology to health care because gaming G medical students, or professionals). For this article we use improves interaction and has a direct impact on human behav- the term ‘‘applied gaming’’ instead of ‘‘serious gaming,’’ ior. ‘‘By the age of 21, the average young American has spent which is a contradiction in terms. ‘‘Serious’’ typically means somewhere between two and three thousand hours reading no fun at all, whereas fun is a characteristic of all games, books and ten thousand hours on playing computer and video although some also have serious applications. games.’’1 The younger generations are no longer learning and Applied games are often used to change behaviors and working as we did, through books. They are not only playing increase motivation to change. Games can engage medical games for fun and entertainment, but using gaming technology personnel and clients in desired behaviors, while their in- in many ways, which is driving this emerging market. This can volvement and pursuit of these behaviors work to solve also be the case for healthcare professionals and patients. (their) problems. Essentially, it takes advantage of humans’ This article for healthcare organizations introduces the psychological predisposition to engage in gaming. Game Maturity Model as an extension to the general Game Games can have a wide variety of possible objectives, Maturity Model article.2 In the current health market, orga- areas of application, complexity, and levels of voluntariness, nizations constantly face more and more pressure to gain and depending on the goal of the game. Internal gamification retain a competitive advantage, to identify ways to cut costs, to focuses on processes inside the organization, such as training improve quality, and to reduce (the risk of) errors. Gamifi- medical students to perform complex diagnoses and treat- cation may help organizations to address and resolve these ments. Internal gamification focuses on finding fun in the problems. To help organizations introduce and improve their things an employee has to do, to increase motivation and use of gaming, this adapted Game Maturity Model can help performance. External gamification focuses outside the or- healthcare organizations quickly determine their target posi- ganization, such as patient-related gamification. The focus tion and develop a roadmap for moving toward their target. here is trying to enhance the patient’s user experience. Ide- First, the meaning of the term ‘‘applied’’ or ‘‘serious’’ ally, the end goal is incorporating games into the ecosystem games is briefly discussed. Next, this article shows the design of the health organization. Some game applications may of the Game Maturity Model and the way it can be used by incorporate multiple complex tasks, such as a game that healthcare organizations. Last, two case studies of health helps surgeons practice surgeries, but may also be related to games are presented as examples of the successful use of more common tasks, such as compliance training. games in health care. Current game applications in healthcare often focus either on treatment for patients or on training for medical students Applied Games and Gamification and personnel. Some advanced forms stretch our imagination Serious or applied games are models or simulations of by aiming to fight cancer or changing the way we build real-world events or processes, designed for the purposes of cities. Common game techniques include achievement

KPMG Advisory, Amstelveen, The Netherlands.

1 2 DE BOER ET AL. badges, achievement levels, leader boards, progress bars widely used model focused on the domain software devel- (indicating how far from completing the task the user is), opment and maintenance of an organization. The model virtual currency, systems for awarding and exchanging, distinguishes five levels: the initial, repeatable, defined, challenges between users, etc.3 managed, and optimizing levels.

Maturity Modeling The Heath Game Maturity Model A maturity model basically indicates at what level an or- An organization can implement several focused gaming ganization is within a specific domain. Maturity models are solutions to discrete problems or can integrate gamification used as an evaluative and comparative basis for improvement into its overall strategy. Games can focus on general training in order to derive an informed approach for increasing ca- or behavioral change and can even teach medical knowledge pability of a specific domain within the organization. A and skills. Each of these approaches helps identify the ma- maturity model evaluates an organization only in one spe- turity of an organization in regard to games. Maturity mod- cific domain and ranks an organization in one of the levels of eling can help identify the current position of a healthcare maturity defined. The scope of a maturity model aims at the institution and the steps to proceed to the next maturity level. organizational entity on which the model is focusing. The For instance, games can be applied to make a task more fun model presented in this article has been adapted to gaming for employees, without necessarily achieving benefits like for healthcare institutions. behavioral change or learning. This would indicate a lower Maturity models typically include a sequence of levels (or level of maturity in comparison with an organization that stages) that form an anticipated, desired, or logical path from implemented games to contribute to the actual healthcare an initial state to maturity. Basically, maturity models consist execution. of several maturity levels or stages, with a typical evolu- The model distinguishes four perspectives, each with five tionary path through these stages. The first stage indicates an maturity levels. The model has five levels, which reflect the organization (or process) with few capabilities in the domain Capability Maturity Model.4 The four perspectives are re- the model is covering. Low maturity can in general be de- lated to (1) the value that is produced with games, (2) the scribed as uncoordinated, reactive, internally focused, low process in place in the organization to support the game resourcing, naive, and static. In contrast, the highest stage strategy, (3) the company-wide coverage applied to games, represents an organization with total maturity in the specific and (4) the technology used for games to be a success. Or- domain. High maturity can be described as organization- ganizations should rank themselves on each of the four wide focus, proactive innovation, efficient resourcing, and perspectives to assess the level of maturity and the contri- comprehensive understanding. A maturity model functions bution of games to their strategic goals. as a scale for assessing an organization’s position on the evolution path and specifies characteristics that need to be in Value place for an organization to be described as being at a par- The first perspective of the model is related to the value ticular maturity level. Between the initial and mature phases generated through games. The Game Maturity Model for are growth phases. health care is shown in Figure 1. In management, maturity models allow for better posi- The lowest level of value generated through games iden- tioning of the organization and help to stimulate continuous tifies organizations with no games at all. Healthcare orga- improvement. A maturity model can help health organiza- nizations that do not use game techniques in their treatments tions in quickly assessing their current position and devel- or services would be scored in this level. oping a roadmap for improving their domain position from The next level applies to games that are used solely for the current to the desired levels. pleasure and not yet for actual healthcare results. The effect is short term and focused on getting a dopamine effect (a Maturity Models and Applied Gaming rush). These games would not have a real purpose (yet). This The need for a game maturity model is growing rapidly as would be the case if an organization lets its employees or organizations relentlessly step up the pace and size of in- patients play a game just for entertainment, without ex- vestments in applied games, but they lack experience in or- pecting results or improvements out of this. ganizing their gaming capability. Within 5 years healthcare In the next level, called ‘‘passion,’’ flow and engagement organizations will likely come under increasing pressure to are central. A healthcare organization in this level uses game achieve above-average performance using applied games as techniques to enhance its employees or patients, encouraging they are a cost-efficient method to train and maintain the them to spend more time than they otherwise would have skillset of students and personnel (even professionals). The spent on this activity. An organization that uses gaming various stakeholders (including top management and leading techniques for learning and healthcare simulation would be medical professionals) will insist on direct, increasingly scored in this level. It is argued that when people are in the transparent insight into whether incorporating applied games state of ‘‘flow’’ they can concentrate on a subject for a long into institutional operations yields added value that justifies period and very intensively without distraction.5 Games the investment required. enhance this state and can therefore engage customers or In developing this Gaming Maturity Model, we compared teach employees. the model with other relevant maturity models in terms of the The fourth level, ‘‘purpose,’’ applies when there is a higher problem, target, and demand. The concept of measuring the purpose to applying games. For instance, the games relate to maturity of an organization was introduced with the Cap- the strategic business goals such as changing the mindset of its ability Maturity Model4 by Carnegie Mellon University. This employees or curing or saving the lives of patients. GAME MATURITY MODEL FOR HEALTH CARE 3

FIG. 1. The Game Maturity Model for health care. Color images available at www.liebertonline.com/g4h

The last maturity level, ‘‘profit,’’ describes game initia- The second level indicates that some individuals within tives that actually succeed in obtaining financial profit or the organization apply games, but there is no widespread non-monetary benefit (e.g., improving the quality of life for a implementation throughout the organization. patient with Parkinson’s disease or improving compliance The next level, ‘‘entity,’’ indicates that games are used by with regulations by playing a ‘‘compliance game’’). some groups or departments. Currently, education and training departments are the early adopters of game tech- Process niques. For instance, games may be used to simulate emer- gency situations, which can increase patient safety by The second perspective of the Game Maturity Model re- providing students and healthcare professionals with a safe lates to the processes in place to support games. learning environment to practice emergency medical skills, In the initial ‘‘ad hoc’’ level, game processes are unpre- as in ‘‘abcdeSIM’’ created at the Erasmus University Med- dictable, poorly controlled, and reactive. Problems in the ical Centre.6 game processes are only solved after they appear. At the fourth level, the application of games is spread In the next level, repeatable processes for game pro- throughout the institution. Games are an important topic on jects are developed, but the organization still acts the board level and are used in many different ways (e.g., reactively toward games. It is an improvement over the education and training purposes, patient interaction, and lower level in that knowledge already gained will not be healthcare treatments). lost because project management capability has been The highest level is where the healthcare ecosystem is developed. involved in the application of games. Not only employees of In the ‘‘defined’’ level, a healthcare organization starts to the health organization itself, but also patients, suppliers, and act proactively toward game processes, which become well other stakeholders, are involved in game techniques. Games known throughout the organization. are applied externally. For example, the airline KLM in- In the fourth level, game processes are part of healthcare volves customers of their loyalty program in optimizing procedures, so the outcomes of game initiatives are measured company processes through playing a game called ‘‘Aviation and controlled. Empire.’’7 In the highest level, ‘‘optimized’’ processes around games are organized, managed, and well known. The focus has Type shifted toward continuous improvements by empowering employees of an organization to generate long-term benefits The fourth perspective of the model relates to the different through applying processes around games. types of games that are used by an organization. There are many types of games and many ways to cate- gorize them. The types described in Figure 1 are benchmarks Coverage and chart an evolutionary development. As the levels rise, The third perspective of the model relates to coverage, or the game can be played by more and more users. the ways in which games are applied by organizations. In the first level, traditional offline games are played At the initial level games do not exist. within an organization (e.g., traditional board games). A 4 DE BOER ET AL. healthcare organization at this level sees the benefits of In the next level of maturity, an organization would use games and therefore plays games but does not have the multiplayer game techniques. A multiplayer game involves technology in-house to support this. Board games or paper- more than one player in the game environment at the same based games (e.g., traditional management games) are time. This enhances interaction among the players. Interac- played without the use of technology. These kinds of games tion could take the form of partnership, competition, or have proven to be very effective, but in the Game Maturity collaboration. All are relevant in organizations. Such a Model our focus is on digital games. multiplayer game can help an organization understand the ‘‘Single-player’’ games are digital. In this level online social contexts in which situations happen. single-player games support the game strategy. In a single- The fourth level involves specific groups of people who player game input from only one player is expected with no are playing the game together in a virtual environment. The collaboration between players. Dutch Ministry of Defense,8 for example, uses this kind of

Table 1. Application of the Game Maturity Model Description of example Perspective ‘‘abcdeSIM’’ by Erasmus University Medical Centre ‘‘Geriatrix’’ by Radboud University Background The goal behind this game is to increase patient safety In this game medical students practice elder care by providing students and healthcare professionals cases. Complex medical reasoning is taught by with a safe learning environment where they can putting them in a situation where they are the practice their emergency medical skills without any ‘‘real’’ doctor. Students are shown a patient case risk to patient health. ‘‘abcdeSIM’’ is based on a and have to choose what steps to take. Students high-fidelity physiological model that contains are giving points based on three factors: patient more than 200 parameters for circulation, respira- preferences, costs, and medical usefulness. tion, and consciousness, which creates a realistic and immersive experience in which the trainee can see the results of his or her chosen diagnostics and treatment. Value ‘‘abcdeSIM’’ is ranked at the levels of both ‘‘pur- The game can be categorized at the level of pose’’ and ‘‘profit.’’ It increases the knowledge and ‘‘purpose’’ as the students learn reasoning that is skills of emergency medicine through simulation of hard to acquire out of a book. In a book, students various types of acutely ill and injured patients could learn the medical protocol, but in the while at the same time taking the risk of errors game, ethical choices are also important. The involved in real-life cases out of the equation. game can be categorized within the category Moving beyond achieving its instituational purpose, ‘‘pleasure’’ as the game makes elder care more ‘‘abcdeSIM’’ also reduces the cost of training by fun. partially replacing lengthy face-to-face training sessions with virtual online training, which does not require instructors. Preliminary research results showed improved emergency skills for trainees. Process Gaming was ‘‘optimized’’ within the Erasmus Uni- Currently the game is still played on an ad hoc versity Medical Centre. A spinoff company was basis. Students play three cases in one course but created to manage the development and use of do not use this game during other courses. The applied games both within the hospital and by third game gives students a platform where they can parties. The game is continuously improved by add their own developed patient cases, which introducing additional patient scenarios. The use of could be used by other medical school curricula. applied games positively influences the training The goal is to make a licensing system behind process by reducing time and financial expenses. the game for others to use. Coverage The coverage of applied games is the ecosystem. Over The game is limited in its scope of coverage to the 1000 doctors in The Netherlands currently use the geriatric care of the program at Radboud ‘‘abcdeSIM’’ game. Also, ‘‘abcdeSIM’’ is being University. Around 200–300 students play the introduced abroad with contracts in medical insti- game each year. Greater coverage is possible tutions in two other countries. Erasmus University throughout this and other healthcare institutions Medical Centre is investigating the introduction of or even the larger ecosystem, as the game can be applied gaming outside the domain of acute health easily copied to other courses at Radboud or care, in various other academic fields at Erasmus other universities. University. Type The game uses single-player techniques and some The game uses single-player techniques. Each multiplayer features. The simulated treatments are student plays the game in a solitary environment single-player challenges. However, game competi- and cannot affect the gameplay of other users. tions have been held at four academic conferences There are no real plans to change this. The first between doctors and nurses, which is a multiplayer goal is to implement the game at other univer- characteristic. These competitions were very en- sities and in other courses to change the way gaging and enjoyed by the players. students think and behave. GAME MATURITY MODEL FOR HEALTH CARE 5 game to train groups of a hundred or more soldiers to prepare The maturity of an organization is a determining factor for them for their international missions. the way in which games develop. It can provide good support The highest level of maturity involves massive multi- to managers, doctors, and health workers to make more in- player online games, which are often Web browser or con- sightful and better decisions for achieving care objectives. sole based, in which very large numbers of players interact Applying games in a healthcare context is not a one-off with one another within a virtual game world. Massive event. The Game Maturity Model may be used as a start and multiplayer online games build the ultimate collaboration as a model for ongoing reference. Healthcare instutions can and can generate insights by making use of the behaviors of no longer afford to see games as an activity that we do in our real-life people who play the game. This type of game en- spare time or that is something for kids. Games are dominant ables healthcare organizations to experiment with new in our real lives and can lead to new forms of collabora- strategies in a close-to-real-life setting. Promoting collabo- tion and innovation. The real challenge today is how to in- ration can result in new and innovative solutions to problems. tegrate games more closely into our everday lives, as well as ‘‘Very big games represent the future of collaboration and how to embrace them as a platform for collaboration on our may be the best solution for solving the most complex most important efforts.2 The opportunities in health care are problems of our time.’’2 immense.

Case Studies Author Disclosure Statement There are many examples of applied games in health care. No competing financial interests exist. We have picked two examples to demonstrate the strength of the Game Maturity Model in the healthcare domain: ‘‘abc- References deSIM’’ by Erasmus University Medical Center and ‘‘Ger- 1. McGonigal J. Reality Is Broken: Why Games Make Us Better iatrix’’ by Radboud University. The outcome of the and How They Can Change the World. New York: Penguin application of the Game Maturity Model is shown in Table 1. Press; 2011. 2. De Boer J, Geert A, Adriani P. Game Maturity Model. Conclusions Compact Mag 2013; 4:48–54. In a healthcare environment, the Game Maturity Model 3. Wikipedia. Gamification. 2013. http://en.wikipedia.org/wiki/ Gamification (accessed January 26, 2016). links the vision and a strategic plan into concrete objectives for applying games in healthcare situations and processes. 4. CMMI Product Team. Capability Maturity Model In- These objectives must be organized along the four different tegration (CMMI SM), Version 1.1. Publication number SEI- 2002-TR-012. Pittsburgh: Software Engineering Institute, perspectives: value, process, coverage, and type. Carnegie Mellon University; 2002. Applying games in organizations should follow steps that 5. Hsieh T. Delivering Happiness: A Path to Profits, Passion, correspond to the growth in the organization’s maturity. As and Purpose. New York: Business Plus; 2010. an organization matures and a better equilibrium is estab- 6. abcdeSIM. Applied Games for Healthcare Professionals. lished among the different perspectives, the integration 2012. www.abcdesim.nl (accessed January 26, 2016). throughout the organization becomes clear. 7. KLM. KLM Aviation Empire. 2013. https://game.klm.com/ During the first growth level, games are managed in (accessed January 26, 2016). the short term and mostly by individual front runners. In the 8. Ministerie van Defensie. Wereldwijde training via Serious second and third levels, more emphasis is placed on the Gaming. 2013. https://www.defensie.nl/actueel/nieuws/2013/ strategy of how to apply games specific to a healthcare 04/12/wereldwijde-training-via-serious-gaming (accessed institution. The focus, however, will be internally driven. January 26, 2016). The relationships among the different perspectives (value, process, coverage, and type) are not in place in the lower Address correspondence to: levels. In the fourth level, the focus on the different per- Paul Adriani, MSc spectives is tight and predominantly externally driven. In KPMG Advisory the fifth level, there is a genuine balance among the dif- Laan van Langerhuize 1 ferent perspectives. Safeguards ensure that the game ma- 1186 DS Amstelveen, The Netherlands turity levels link the healthcare strategy to the healthcare ecosystem as a whole. E-mail: [email protected]