Experience-Based Co-Design and Healthcare Improvement: Realizing Participatory Design in the Public Sector

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Experience-based Co-design and Healthcare Improvement: Realizing Participatory Design in the Public Sector

Sara Donetto, Paola Pierri, Vicki Tsianakas & Glenn Robert

To cite this article: Sara Donetto, Paola Pierri, Vicki Tsianakas & Glenn Robert (2015) Experience-based Co-design and Healthcare Improvement: Realizing Participatory Design in the Public Sector, The Design Journal, 18:2, 227-248

To link to this article: http://dx.doi.org/10.2752/175630615X14212498964312

Published online: 07 May 2015.

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Download by: [193.90.12.89] Date: 21 March 2016, At: 23:31 The Design Journal VOLUME 18, ISSUE 2 REPRINTS AVAILABLE PHOTOCOPYING © BLOOMSBURY PP 227–248 DIRECTLY FROM THE PERMITTED BY PUBLISHING PLC 2015 PUBLISHERS LICENSE ONLY PRINTED IN THE UK

Experience- based Co-design and Healthcare Improvement: Realizing Participatory Design in the Public Sector

Sara Donetto,1 Paola Pierri,2 Downloaded by [193.90.12.89] at 23:31 21 March 2016 Vicki Tsianakas1 and Glenn Robert1 1King’s College London, UK 2Mind, UK

Abstract Over the last decade, growing attention has been paid to the potential DOI: 10.2752/175630615X14212498964312 value of design theory and practice in improving public services. Experience- based Co-design (EBCD) is a participatory research approach that draws upon design tools and ways of thinking in order to bring healthcare staff and patients together to improve the quality of care. The co-design The Design Journal process that is integral to EBCD is powerful

but also challenging, as it requires both 227 Downloaded by [193.90.12.89] at 23:31 21 March 2016 228 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert Introduction organizations, participatorydesign KEYWORDS: experience-basedco-design,healthcare public services. the powerrelations thatcharacterizecontemporary co-design processes shape–andare shapedby– design andtoencouragefurtherresearch intohow aims tocontributethegrowing fieldofservice work withinhealthcare settings.Ourdiscussion of projects andonthechallenges ofco-design implementation andadaptationofEBCDinavariety public services.Inthispaper, wereflect uponthe relationships ofpowerbetween citizensand expectations aspartofareconfiguration ofthe staff andpatientstorenegotiate theirroles and this andsimilar co-designapproaches this paper, in thefuture. With in thehealthcare sectorand(b)anyusefullessonsforimplementing ing theimpacttodateofthis particularformofparticipatorydesign Our reflections seektoexplore inparticular:(a)themainissuesshap- ences withthisparticularapproach (Donettoetal,2014;seeBox1). recent studywecarriedouttomapexistingandforthcoming experi- and ‘grey’ literature reporting onEBCDprojects, andfindingsfrom a tion of EBCD. In doing so, we draw upon peer-reviewed publications has seen thedevelopment, widespread adoption andimplementa- Bate andRobert,2007a).We reflect here onaten-yearperiodthat with, onesuchapproach: Experience-basedCo-design(EBCD; provement byreflecting onourownknowledgeof,andexperiences derstanding ofdesign-informedapproaches tohealthcare qualityim- several importantrespects. design in the healthcare sector remains fragmented and limited in rigorous research intotheimplementationandimpactofservice www.servicedesignresearch.com/uk/; accessed8January2015), network fundedbytheArts&HumanitiesResearch Council:http:// formation are nowunderway(seetheServiceDesignResearch UK mapping theseandotherdesign-ledapproaches toservicetrans- of the services they provide (Carr etal, 2009). Whilst attempts at a suiteofinterventionstohelpNHSorganizationsimprove thequality since 2005 drawn on design theory, tools and techniques to develop Health Service Institute for Innovation & Improvement (NHS III) has healthcare sector–thefocusofthispaperformerNational favour ofmore designinputintheshapingofpublicservices.In + With thisdiscussionpaper weaimtocontributeadeeperun- With Design Commission (2013) recently argued strongly in lic sectorisanemergingandrapidlygrowing field.The Applying servicedesigntheoryandpracticeinthepub- Downloaded by [193.90.12.89] at 23:31 21 March 2016 making improvements toserviceswithout directly involving patients. staff were insteadrelying ontraditional,narrower approaches to time) –were payinginsufficient attentiontotheco-designphase; work tounderstandpatientexperience (muchofitinnovativeatthe observing howearlyprojects –whichdidtypicallyinclude extensive (EBD) the later switch oftitle to EBCD was a direct response to 2007a; Robert,2013).Originally called‘ExperienceBasedDesign’ cally 4–6);and(6)acelebrationreview event(BateandRobert, co-design workinsmallgroups formedaround thosepriorities(typi - ences ofaserviceandidentifyprioritiesforchange;(5) sustained edited 20–30minute‘trigger’filmofpatientnarratives–their experi- carers togetherinafirstco-design eventtoshare –prompted byan filmed narrative-based interviews; (4) bringing staff, patients and ing patientandcarer experiencesthrough observationand12–15 through observationalfieldwork andin-depthinterviews;(3)gather (Figure 1):(1)settingupthe project; (2)gatheringstaff experiences – whichtypicallytakes9to12monthsisdividedinto six stages and thenjointlyreflecting ontheirachievements. TheEBCDcycle identify improvement priorities,devisingandimplementingchanges, carers reflecting ontheirexperiencesofaservice,workingtogetherto studies ofEBCDprojects remain scarce. Iedema with asmallnumberofnotableexceptions(Bowenetal,2013; involve some,more orlessstructured, formofevaluation. However, growing yearonandmostofthecompletedorongoingprojects Australia andNewZealand.Thenumberofprojects appearstobe care), notonlyintheUKbutalsoCanada,Netherlands,Sweden, services, cancerpaediatricdiabetescare andmentalhealth (including, butnotlimitedto,emergencymedicine,drugandalcohol see Box1).Theseprojects spanabroad range ofclinicalareas least afurther27projects intheplanningstage(Donettoetal,2014; have beenimplementedfollowingthepilotproject in2005–6,withat riod between2005and2013,foundthatatleast59EBCDprojects services, exploringthefeatures andadaptationsofEBCDinthepe- pleted, ongoing and planned EBCD implementations in healthcare (Bate andRobert,2007b).Ourrecentsurveyofcom- international in a head and neck cancer service at Luton &Dunstable hospital drew ondesigntheory(BateandRobert,2007a)wasfirstpiloted 2005–6 asaparticipatoryactionresearch approach thatexplicitly quality improvements inhealthcare organizations.Itoriginatedin from participatorydesignanduserexperiencetobringabout EBCD isanapproach toimproving healthcare servicesthatborrows Experience-based Co-design(EBCD) fruitful exchangeswiththedesignsciences. design asapplied tohealthcare quality improvement and tofoster we aimtomakeavaluablecontributionthestudyofparticipatory Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector Through a ‘co-design’ process EBCD entailsstaff, patientsand et al,2010;Piper2012,Tsianakas etal,2012),robust -

229 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 230 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert care organizations ofhowtopositionthemselves withinthepower who lead,supportoradviseon co-designimplementationsinhealth- changes’ (2013:14).Thequestion therefore arisesfordesigners tion to the performance of co-design and in the implementation of which gave ‘rise to particular configurationsofpower both in rela- were ‘initiatedandledbylocalmanagers ofparticularservices’ As Bowenetal(2013)recently reflected, theseearlyEBDprojects about studymethods,seeDonettoetal,2014.) that hademergedfrom the surveyresponses. (For furtherdetails matically toaddress questions andpointsforfurtherexploration transcribed verbatim.Theinterviewtranscriptswere analysedthe- and examinedcloselyforcontentthemes.Allinterviewswere was analyseddescriptivelythrough theSurveyMonkey Subcommittee (RefNo.PNM/12/13-113).Analysis:Surveydata College LondonPsychiatryNursing&MidwiferyResearch Ethics participants; ethicalapproval forthestudywasgrantedbyKing’s were carried out.Ethics review: Consent was obtainedfrom all aptations madetotheEBCDapproach. Atotalof18interviews to securingstaff engagement, thecostsofproject andad- experiences, reflections on the co-design process, approaches choosing the EBCD approach, ways of gathering patient and staff specific aspectsofparticipants’projects, suchas reasons for follow-up telephoneinterviewswere semi-structured andexplored abroad). RecruitmenttookplaceinAugust–September2013.The services/clinical areas andprojects carriedoutboth in theUKand selected (onlycompletedprojects, sampletocoverarangeof ing tobecontactedforfurtherdiscussion,20were purposefully Of thoserespondents whohadindicatedthattheywouldbewill- 2013. Intotal,57participantstookpartinthesurvey. Interviews: the methodology. RecruitmenttookplacebetweenAprilandJune line King’s FundEBCDToolkit; (e)plansforfuture implementationof evaluation oftheEBCDprojects; (d)awareness and use oftheon- required); (b)participants’viewsontheEBCDapproach; (c) formal methodology employed; adaptation of the methodology; training be involvedin(e.g.duration,cost,teamcomposition,stagesofthe tails oftheEBCDproject participants hadbeenorwere planningto participants’ answers)explored thefollowingmainareas: (a)de- reminders. Surveyquestions(1to36questions,dependingon vitation email containing more detailed information and three email survey respondents.Potentialparticipantsreceived Survey: anin- set of18follow-uptelephoneinterviewswithasamplethe57 implementing –orplanstocarryoutanEBCDproject, anda researchers andpractitionersknowntohavehadexperienceof onlinesurveyof Our ‘mapping’studyincludedaninternational et al,2014). Box 1 EBCD ‘mapping’studymethods(adaptedfrom Donetto TM engine Downloaded by [193.90.12.89] at 23:31 21 March 2016 the foregrounding ofexperience,whichis centraltouser-centred Design principlespermeate EBCD.Theapproach isbasedon Service Design,Co-design andEBCD reported intheEBCDandAEBCDpathwayshowthey compare. team (Lococketal,2014)toexemplifythetypes ofservicechanges quickly andatlowercost.In Box2,wereport findings byLocock’s vices) againstwhichtheywere compared, butwere achievedmore those in two previous EBCDprojects (in lung and breast cancer ser AEBCD implementationacross fourserviceswere similarinnature to threatening orchallenging). The48co-designactivitiesresulting from engagement (andmayinsomecaseshavemadetheprocess less rather thanlocalnarrativesdidnotadverselyaffect localNHSstaff readily acceptable to staff and patients and using films of national Research (Lococketal,2014).Theacceleratedapproach proved cancer servicesthrough fundingfrom theNationalInstituteforHealth tested andevaluatedintwoIntensiveCare Units(ICU)andtwolung healthtalkonline.org/; accessed8January2015)–hasrecently been their health-related conditionsheldby healthtalkonline(http://www. archives offilmedinterviewsfocusing onpeople’s experiences of projects). This ‘accelerated’ version – whichrelies on theextensive film (whichhadpreviously drawnsomecriticismfrom staff leading time andcostsinvolvedinproducing filmednarrativesforthetrigger based Co-design–AEBCD)withtheaimofaddressing issuesof ‘accelerated’ versionoftheapproach (AcceleratedExperience- issue ofpowerinco-designworklaterthispaper. networks thatcharacterizetheseexercises. We shallreturn tothe Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector Subsequent developmentsofEBCDhaveincludedtestingan co-design

 teams small

co-design  celebration meeting

event  patients and setting up experiences

gathering

engaging   engaging staff and gathering experiences

 - approach. The sixstagesoftheEBCD Figure 1

231 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 232 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert derpinning EBCD istheparticipatoryapproach totheco-design (BateandRobert,2007b). practical concerns theoretical insight to a change intervention aimed at addressing very social groups have common origins; combining these can bring the meanings andmeaning-making practices ofindividuals and science perspectivesonhow toenablein-depthunderstandingof (Bate andRobert,2007a).Furthermore, design-based andsocial pects of a product or service such as utility, usability and interactivity ‘soft’ elementofthetriadbutratherencompassesfundamental as- (to whichtheanalysisofexperiencecontributesmost) isnotthe 2004): performance, engineering and aesthetics, where aesthetics tend simultaneouslytoallthree dimensionsof‘gooddesign’(Berkun, premise thatsuccessfulquality improvement inhealthcare mustat- focus onpatients’andstaff’s experiencerests onthefundamental that havelongbeenappliedindesign(GageandKolari,2002). The and practicaltools–such as touchpoints and emotionalmapping– human–computer interactiondesign)anditmakesuseofconcepts processes inotherfieldsofapplication(e.g.from product designto Alongside thefocusonexperience, theothercentralthread un- for patientstransferringtoanotherhospitalsurgery) between organizations(improved cross-site informationbooklet summary withinputfrom allprofessions); and1processredesign to remove waste avoiding ICUrest times; redesigned discharge s activities (e.g. changed processsign between service for porters diagnosis; introducing mini ‘Schwartz rounds’); 5process rede teams (e.g. new private room identified for receiving support after V-shaped pillowsforpost-oppatients);21processredesignwithin sourcing clockstoaidpatientorientationinICU;more comfortable test results). InAEBCDthere were: 21smallscalechanges(e.g. link nurseschemetoimprove cross-site workingandvisibilityof redesigned); and2processredesignbetweenorganizations(e.g. exercise; informationflow from pre-assessment topost-surgery physiotherapists reviewed timingtogivepatientsadviceabout (e.g. time forbloodtests);2processredesignbetweenservices sign withinteams(e.g.designatedphlebotomisttoreduce waiting tion; regular updatesonwaitingtimesinclinic);12processrede- small scalechanges(e.g.reviewing andimproving patientinforma- between organizations.IntheEBCDpathwaysthere were: 12 within teamsthanwiderprocess redesign betweenservicesand of activities,withmore small-scalechangesandprocess redesign to 48across thefourAEBCDexamplesandasimilardistribution There were 28 activities across the two EBCD pathways compared (Locock etal,2014:44). changes resulting from EBCDandAEBCDimplementations Box 2 Examples ofchangesresulting from co-design:service - Downloaded by [193.90.12.89] at 23:31 21 March 2016 of howtheconcept translatesintopractice butiscentred onfour by BradwellandMarr(2008) leaves room formultipleinterpretations (Donetto wishing they had paid further attention to its role and significance crucial stageofEBCDvaried widely, withsomeofourparticipants ties aspartoftheirEBCDprojects, inpracticetheirapproach tothis cent ofsurveyrespondents reported implementingco-designactivi - worldwide intheperiod2005–13,wefoundthatalthoughover 85per our studyofresearchers’ andpractitioners’experienceswithEBCD and workshops. As we discuss in more detail in the next section, in user testing,andfrom onlinecollaborationand/oruserresearch practised differently, rangingfrom feedbackand consultationto design’ indifferent servicesandsectors.Andco-designisalso 2011: 20). (Cottam andLeadbeater, 2004:22;see alsoMeroni andSangiorgi, with professionals and front linestaff todevise effective solutions’ service usersas‘vitaltothedesignanddeliveryofservices,working – entailingtheuseofdistributedresources andthe participation of of ‘co-creation’ –asproposed byCottamand Leadbeater(2004) designers’ anymore (Carretal,2009).Italsodrawsuponthenotion where ‘thepracticeofdesigningisnot exclusivetoprofessional science thisispartofamajorshifttowards anewrole fordesigners the ideagenerationstage(SandersandStappers,2008).Indesign expertise (knowledge)andparticipateinthedesignprocess from of expertise; patients are called to share their specialist form of healthcare servicesinorder toincludenewstakeholdersandforms ment inEBCDaimsatopeninguptheboundariesofdesigning healthcare organizations. which co-design aims to bring about raises within contemporary the potential challenges that the reconfiguration of power relations it hasbeenappliedinEBCDprojects todate;finallywe reflect upon in thecontextofEBCDbefore presenting whatweknowabouthow practical challenges.Belowweprovide abriefoverviewofco-design co-design asadvocatedinEBCDpresents bothconceptualand Lenihan andBriggs,2011).However, aswellimportantbenefits, and socialjustice(BradwellMarr, 2008;Iedemaetal,2010; ment anddisillusionmentfrom citizensaboutpolitics,democracy from contemporarysocietalchallengesandtoaddress disengage- as awayforpublicservicestorespond totheincreasing pressure Simonsen, 2013:4–5).Participatorydesignapproaches are seen acknowledged participants inthedesignprocess’ (Robertsonand the users’role from beingmerely informantstobeinglegitimateand where participationrefers to‘thefundamentaltranscendenceof to participating intheshapingofworlds in which theyact’, ipatory designgivesprimacy‘tohumanactionandpeople’s rights processes thataimtobringaboutqualityimprovements. Partic Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector In theUK,there isconsiderable variationinwhatistermed‘co- Drawing upon participatory design principles, the co-design ele- et al,2014).Theworkingdefinition ofco-designprovided

233 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 234 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert EBCD approach – with orwithoutthehelp of the toolkit – have projects. the experienceofpatients,staff andcarers involvedinotherEBCD lighted theuseofvideosin toolkitasahelpfulwayofillustrating the practicaltoolsforcarrying outanEBCDproject. They alsohigh- found itconciseandeasyto follow, andthatitprovided them with feedback. Oursurveyresponses indicatedthat usersofthetoolkit and wasrecently updated toitssecondversioninresponse touser average of around 3,500 views per month (Adams online viewsreached almost11,000–thetoolkithasreceived an approach. Since the launch of the toolkit in August 2011 – when passing on hints and tipsfor others who may be interested in the participants inprevious projects talkingabouttheirexperiencesand joint patient-staff event’),each ofwhichincorporatesvideoclips (for example,‘Interviewingandfilmingpatients’‘Running the accessed 8 January 2015). The toolkit is divided into 16 sections King’s Fund charity (http://www.kingsfund.org.uk/projects/ebcd; ment practitionersandacademicsdisseminatedthrough the developed in2011through acollaboration betweenqualityimprove- free-to-access, onlinetoolkitincorporatingseveralcasestudieswas able toanyonewithaninterest inhealthcare qualityimprovement, a In order tomaketheprinciplesandpracticesofEBCDwidelyavail- Lost inTranslation? Co-design andtheImplementationofEBCD: Robert, 2007a:30). care but actively contributing to the design of their care (Bate and needs; patientsare notjustactivepartners‘havingasay’intheir more thanjustbeingresponsive topatientsandlisteningtheir sionals withintheNHS(BateandRobert,2007a).Co-designmeans to partnershipandshared leadershipbetweenpatientsandprofes - In EBCD,the‘co’inco-designwasintendedtorefer emphatically • • • • these dimensionsasfollows: outcomes andintent.InthecaseofEBCDwewouldoperationalize elements: participation,development,ownershipandpower, and By andlarge,practitioners researchers whohaveusedthe to occurascollateraleffects oftheprocess. standing that unplanned processes and transformations are likely outcomes andintent:co-designhasapracticalfocus,not generate collectiveownership;and ordinary powerrelations betweenstakeholdersandaimsto ownership andpower:co-designinvolvesatransformationof adapting asittakesplace; development: co-designevolvesasaprocess, maturingand many stakeholdersaspossiblehaveinput; participation: co-design is a collaborative process in which as et al, forthcoming) with Downloaded by [193.90.12.89] at 23:31 21 March 2016 responses for more examples tobeprovided ofco-design meetings struggling with thenotion of co-design itself,askingintheirsurvey design groups’. Itisclearthatsomeofthoseleadingprojects are still described above). tion for thedevelopmentandtesting of the ‘accelerated’ approach our study(Figure 3): itsimply takes toolong (therein liesthejustifica- to themaincriticismmadeofEBCDapproach byparticipantsin to focusgroups. Manyof the adaptationswehaveobservedrelate pensed withone-to-onestaff and/orpatientinterviewsandresorted and resource-intensive) filmed component, whilstothers have dis- conducting patientinterviewsmanyhavedispensedwith the(time- common omissions,althoughover80percentofprojects reported and thecelebratory/review event(Figure 2).Beyondtheseobvious phases, particularly–itwouldappearnon-participantobservation These local adaptations have included the elimination of specific own localcontexts: flexible, tailoringittothenature ofparticularclinicalservicesandtheir the implementationofEBCDperceive theapproach asinherently From oursurveyandinterviewdata,itwasclearhowthoseleading to avarietyoflocalcontingenciesandorganizationalcircumstances. Robert (2007a)hasundergoneavarietyofadaptationsinresponse responses –is thattheEBCDapproach proposed byBateand limited publishedliterature –aswellfrom analysisofthesurvey cent saidit‘really engagedstaff.’ However, whatisevidentfrom the reported thatEBCD‘really engagedpatients’andalmost80per found it promising. Over 90per cent of respondents inour survey Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector Most significantinourview are theadaptationsto ‘smallco- evolving onesofourown.(Interview#18) with patients.We usealotoftoolsfrom servicedesign andare evolve andgrow as organizations grow smarteraboutworking osophy andonlysecondamethod,methodsneedto opportunity orconstraintsarise.IthinkEBCDisfirstaphil We havealready introduced arangeofmodificationsas account thesituationandtimeframe.(Respondent#47) [a] different approach andtakinginto buildingonourlearnings management approach. Each project since has involved with abiggerproject whichadoptedatraditionalPDSAproject servicedesigner.expertise ofanexternal We alsopartnered together. We hadastrong servicedesignelement,utilizingthe relied strongly mapping and identifying priorities on journey and patient workshops, rather we hadjoint workshops. We to getamandateforthework.We didn’t haveseparate staff stories through workshops. We had a pre-project workshop project asanexample,wedidn’t usevideosbutcollected re [sic]co-designisevolving.UsingourfirstOur learning

235 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 236 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert et al,2014). approach (source: Donetto Adaptations totheEBCD Figure 2 Weaknesses oftheEBCDapproach (source: Donettoetal,2014). Figure 3 Celebration/review event Small co-designgroups toworkon… Patients andstaff co-designmeeting Patient interviews Staff interviews Non-participant observation Patients/carers didnotengagewiththeproject Staff didnotengagewiththeproject It costtoomuch It wastoocomplicated It tooktoolong Thinking aboutyourproject/s, whatwere theweaknessesofEBCDapproach? Which elementsofEBCDdidyouimplementinyourproject? had told us the issues and just wanted to learn whatchangeswe had toldustheissuesandjustwantedtolearn co-design groups were ‘mainlystaff asmostpatientsfeltthatthey ing the‘solution’.Anotherproject leaderdescribedhowthesmall patients present; staff were thenchargedwithdevelopingandtest- experiences were discussedandsolutionsdeterminedbutonlywith project whichentailedholdingjustone‘co-design’meetingwhere a wide range of approaches. Somestark examples included one their project (seeFigure 2),follow-uptelephoneinterviewsrevealed respondents reported implementingco-designactivitiesaspartof ‘shortcuts’ could be made. Although over 85 per cent of survey events work,the ‘fundamental’ aspects of co-design andwhere and the tools used, more information on how to make co-design Answered: 45 Answered: 41

(Please tickallthatapply) 0

0 4 5 7 7 2 Skipped: 12 Skipped: 16 10 203040 2 4 14 15 15 6 19 7 8 10 1214161820 11 11 33 33 37 38   No Yes 19 Downloaded by [193.90.12.89] at 23:31 21 March 2016 Locock service area are themost commonresult ofbothAEBCD andEBCD, Although small-scalechanges andprocess redesign withinone were similarinnature andscaletothosetypicallyseeninEBCD. proach ledto48co-design activitiesacross fourservices,andthese As noted earlier (see Box 1)the ‘accelerated’ EBCD (AEBCD) ap cancer service: colleagues (forthcoming)oftwomembersstaff inacolorectal care context;witnessthecontrastingviewsreported byAdamsand from co-designapproaches is alsoaninteresting onein the health- The questionofexpectationsthescalechangethatmayresult further attention: the significanceofco-designtowhichsomewishedtheyhadpaid (Bowen was donebyothers’akeyshortcominginthisparticularproject that areported ‘perception of thedesigning as beingsomethingthat turing ofparticipationandthelimitedideationtoolsinEBD’,arguing service improvement thatresulted maybeduetothespecificstruc- services forolderpeople.Theseauthorssuggestthat‘themodest the applicationofEBDinanearlycasestudyinvolvingoutpatient had made’. This accords with Bowen et al et al(2013)were clearlyleftalittle underwhelmed bythechanges have recently referred tothis as ‘sweatingthesmallstuff’. Bowen can beimmenselyvaluableto patients.Moore andBuchanan (2013) markably complextoimplement, andwhatlookslikeasmallchange Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector al, forthcoming) experience for100people,howwonderfulisthat?(Adams et change affects 100peoplethatyear, andit’s abetter [People talkaboutminorbut]Howminor?…ifthat little bit…that’s good, butisthatgoodenough? to get some really good stuff out of it … changing [things] a [for] theamountoftimeit[theEBCDprocess] takesyouneed I wouldhavebenefittedfrom more co-design.(Interview #05) of domore feedbackasyougoalongreally. Ithinkdefinitely I think I would probably do more co-design events and sort it really drove themtocompleteactions.(Interview#08) that I said before about that humanistic kind of connection that was somethingabout,definitelyforstaff becauseofthatthing their actionpoints.Imeantheydiddivvythingsup…there relatives tobethere kindofheldthestaff toaccount,and keeping in close contact. And Ithink for the patients and What workedforuswasthefrequent shortmeetings,and et al,2013:241–242).Participantsinourstudyreflected on et al (2014) observed that small-scale change isoften re - ’s (2013) reflections on -

237 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 238 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert 2012). Interviewparticipantsinourstudycommented: (Boyd have proved powerfulbutstillcomplextoimplementinpractice Where successfullyimplemented,theco-designstagesofEBCD comment that: is theco-designphaseofapproach. Interestingly, theauthors would certainlyagree withtheauthorsthatonekeyarea tofocuson observed intheirproject (relative expectationsbeingone)butwe several potentialreasons whyonly‘modest’improvements were brought aboutintheEBDproject theyled.There are, ofcourse, reverted back to a much more hierarchical way of organizing within theorganization,co-designed uptoapoint,andthenit … Ithinkyoucanthenidentify howthehierarchies worked managers. Sothere wascertainlynoco-design atthatpoint the frontline managers, the nursing managers, and their line were actuallygoingtodo,thosedecisionswere takenby could beimproved, butwhenitthencamedowntowhat they tried toidentify, incollectivediscussion, where orhowthings We gottogetherand we discussedthenarrativesand mandate from patientstochange things.(Interview#17) a hugepayoff becausestaff thenfeeltheyhaveaveryclear So youknowthere’s adifficultyengagingpeople,butthere’s disempowered and frustrated, and away we go you know. they realize theyactually feel thesameway, they bothfeel almost usually 20-minutes, a kind of a stand-off. And then they’re often very nervous initially, and I can almost time it, it’s the firsttimethey’veevertalkedwitheachotherthatway. So patients inco-designistheserviceconnotations;it’s often co-design andparticularlytheconversationbetweenstaff and detachment thatactuallygetsintheway. WhatI’vefoundwith afford tobe;youjustseetoomuchtragedysohavea their empathy, theybelievethey’re empathetic,buttheycan’t Cynical inthatthey’veseeneverythingtried…Andprobably because theirlivesare soregulated …they’re oftenverycynical. that, butitdoesn’t alwaysworkforcliniciansinmanagement Co-design isverymessy, andI’mtotallycomfortablewith (Bowen etal,2013:242) own morale and confidence about the impact of the work. other inputs to stimulate the actual changes, challenged our that project proposals have been adapted and fused with uneven) progress from ideas to implementation, and the way unfamiliar andcomplexorganizationalcontexts.Theslow(and trajectories ofchangecanalsobenaivewhenworkingin our ownexpectations(asparticipatorydesigners)about et al,2012;Iedema2010;King’s Fund,2011;Piperetal, Downloaded by [193.90.12.89] at 23:31 21 March 2016 interviewees: league required byco-designwork.Inthewords ofoneour ‘expert’ and‘decision-maker’ role andthatofpartnercol- staff canfinditverychallengingtomovebetween theirfamiliar that, whilstrecognizing thepotentialofco-design,most healthcare Our interview data offered another staff perspective on this issue: process: working –ascliniciansalongsidetheirownpatientsina co-design participating inthisproject considered theemotionaldemandsof managers andclinicians(King’s Fund,2011).Onememberofstaff tion ofsomegroups, whichendedupincludingmainlyorexclusively subsequently maintainedandthere were issueswiththecomposi- proved challenging:notalltheco-designgroups that formedwere breast andlungcancerservicesintheUK,co-designstagesalso worked lesswell(Piperetal,2012).InanEBCDproject carriedoutin ment offront-line staff were notpossibleorconsistent,co-design However, where preparation, recruitment ofpatientsandengage- vice andinsights of patients and frontline staff (Iedema et al, 2010). enabling theservicetoimplementsolutionsthatmetwishes,ad- were qualitativelydifferent totraditionalformsofengagement;and and carers; engaging service users in ‘deliberative’ processes that the impactofhealthcare practicesand environments onpatients staff newskills;enablingfrontline tolearn staff bettertoappreciate demonstrated anumberofstrengths including:allowingproject Emergency DepartmentsinNewSouthWales, Australia,co-design Despite itsinherent complexity, intheEBCDprojects carriedoutin Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector brilliant herlifeis…(Adamsetal,forthcoming) had comebackinthenextclinic…andshe’s tellingmehow at herscanandIwasgoingtohavetellthatcancer across a[meeting]tablefrom awomanthatI knew, I’dlooked [The co-designgroup was] nervewracking…Iwassitting doing, andhowtodoitbetter. (Interview#07) that’s avaluabletoolininformingservicesofwhatthey’re knocked overyetasfarlivedexperiencebeingsomething do theyknow, youknow. Sothere’s juststillthatwalltobe patient [and] carers who are just the receivers of service, what And it’s aboutthatmedicalmodelIthink,where you’vegotthe it hard tosee where doesitfitinwithwhatwecurrently do. the processes they’vealready got.AndIthinkthey’re finding go forward withthings,butalotoftheservicesare steepedin I thinkthere’s averybigrecognition ofco-designasawayto #02) taken away and worked on behind closed doors. (Interview things … a workshop with a draft action plan which was then

239 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 240 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert pants intheprocess. and the developmentof trust and new relationships betweenpartici- the process; changesinstaff motivation, skillsandself-confidence; include, for example: the personaldevelopment of those involved in (Bradwell andMarr, 2008;Iedemaetal,2010).Otheraspectscould and cannotbereduced solelytothedesignsolutions itgenerates intervention whoseimpactand outcomesare difficult to evaluate their and our considerations is that co-design is acomplex social policy-makers (Iedemaetal,2010).However, whatemergesfrom ness’ assessmentandobtainingrecognition from managementand using amixofinvolvementstrategies,performing‘co-design readi- processes inEBCD–for example, byinvolvingskilledfacilitators, their ownrecommendations astohowimprove theco-design projects carriedoutinAustralian emergency care servicesmake and itsactualformsinpractice.Theauthorsinvolved the EBCD often reveals tensions between the intended aims of co-design detailed implementationofparticipatoryapproaches suchasEBCD they are successfulinthisregard. Diggingalittledeeperintothe is veryscant;certainlyweknowlittleofthecircumstances inwhich evidence astowhetherornottheydosointhehealthcare setting the aimtochangepowerrelations but,aswediscussbelow, the ering suchinsights.Implicitinparticipatorydesignapproaches is patient levelinthehealthcare sectorbecome clearer whenconsid- The complexitiesof‘co-design’attheindividualstaff memberand design asapersistingchallenge: Medical Centre intheUSAbeginning in 2008,Plsekhighlightsco- Mason as partofanorganization-wideLeaninterventionatVirginia In hisaccountoftheimplementationoriginalEBDapproach 171) initial stepsthatseemtoleadindirection. (Plsek,2014: Mason’s future buttheorganizationis committed to taking […] getting to full co-design may still lie further out in Virginia in largenumberssothattheyfeelevenmore empowered design, trainingthemtobeassertive,andengaging members tobeequalpartnersindecisionmakinganddetailed It involvesdeliberatelyempoweringmultiplepatientsandfamily … thefullconceptofco-designinEBDprovokes achallenge. in chargeofmakingthingshappen.(Interview#10) phase becauseIthinkhealthprofessionals are usedtobeing co-design orcollaborationafterthatinitialproblem-solving stories, it’s likeconsultation,Ithinkthatit’s harder todothe it mighthaveslid…Ithinkpeopleenjoythebitofcollecting other toaccount.Andkeptpeopleontrackwhere perhaps were mixedgroups ofpeopledoingthework,theyheldeach I thinkthatitworkedbecausewascollaborativeandthere Downloaded by [193.90.12.89] at 23:31 21 March 2016 the different types andfacetsofpoweroperating withinaspecific clearly demarcated; and,second,withoutcriticalunderstanding of contexts where traditionalroles ofprovider andrecipient ofcare are mutual respect thatare proving difficulttoestablishinhealthcare herent to co-design are notions of equality, equal contribution and public services are long overdue for at least two reasons: first, in- operate andare transformed–ifatallinco-design workwithin survey, wesuggest thatin-depthanalysesofhowpowerrelations co-design phaseofEBCDdocumentedbyresponses toourrecent the publicsector)anduncertaintyconfusionaround the view ofthespread ofEBCD(andsimilarapproaches throughout However, studieswiththisfocushave notyetbeenundertaken.In processes fordemocraticdeliberation(Iedema etal,2010:84). mobilizes ‘dialogicalinnovation’through instantiatingthespaceand researchers havecalledforacloserexaminationofhowco-design the implementationofchanges(Bowenetal,2013:14);similarly, specific configurationsofpoweronthe process ofco-designand EBCD havehighlightedtheimportanceofattendingtoeffects of ‘transformation design’inSangiorgi,2011).Andyetpractitionersof neglected tolookatpowerindetail(see,forexample,thecaseof design workfocusingonempowermentandparticipationhavealso exceptions (e.g.BratteteigandWagner, 2012)current strandsof power relations withintheseprocesses (Farr, 2013);withfewnotable argue – largely failed to critically engage with issues of power and To datetheco-designandco-creation literature has–wewould and domobilizeaffect powerrelations amongstparticipants. and more critically at the ways in which co-design practices can need forservicedesignersandresearchers to lookmore closely vision rathercomplex.Atthispointwewishtodrawattentionthe suggests thattheeverydayreality ofpracticemakesachievingthis certainly evidenceemergingaround theimplementationofEBCD cessful co-designisclearlysomethingofanidealcasescenario; Bradley andMarr’s visionofthepowershiftinherent withinsuc- central toco-design.InBradwellandMarr’s words: between stakeholders and the generation of collective ownership are As mentionedearlier, thetransformationofordinary powerrelations Power RelationsinCo-design Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector collective ownership.(2008:17) those inatraditional‘client’role, servestocreate a senseof whom itusuallyrests, andtheconcomitantempowermentof combination ofcontrolled abrogation ofpowerbythosewith suggestions entaillarge-orsmall-scalechanges.This legitimacy andvalueininputsfrom allthoseinvolved,whether and freedoms between participants. There isequality of that definesandmaintainsthenecessarybalanceofrights Co-design shiftspowertotheprocess, creating aframework

241 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 242 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert argue: design, innovationandimprovement, isthat,asCribbandGewirtz and userengagementdiscoursesinthecontextofpublic services lem withmuchofthewell-intentionedmobilizationcollaboration conditions inSalmonandHall,2003orThilleetal,2014).Theprob - disempowering effects ofdiscourses ofself-managementchronic to underminecare equityinSindingetal,2012;orthepossible the potentialofdiscoursespatientinvolvementincancer care contribute toreinforcing orreproducing them(see,forexample, which aimtochallengeexistingpowerconfigurationscan, infact, power relations operateinhumaninteractionandhowdiscourses useful. Analysesofdiscoursesare remarkably aptto illuminatehow focus ondiscoursesofinvolvementandcollaborationisparticularly professional andpersonalboundaries’(Iedemaetal,2010:86). spaces andnewdiscoursesthat‘traversepeople’s sociocultural, to challengeexistingdiscoursesbyinstantiatingnewdiscursive with a‘democratic’modelofserviceuserparticipation–thepotential from Iedemaandcolleaguesthatco-design(inEBCD)has–inline previously examined.Thisobservationresonates with thesuggestion occasion canbegintobringlightissuesthatinstitutionshadnot ertheless, she observes, these activities and theinteractions they the waysinwhichcitizenparticipationisframedandenabled;nev- fundsforsuchinitiatives),withsubsequentlimitationsto external and hostedbyinstitutions(whichalsousuallyobtainmanage points outthatco-designactivitiesandprojects are usually initiated and/or provision ofservices.EchoingBowenetal(2013),Farr(2013) making pathways,bringingabouttransformationinpolicy, culture lenging existing conceptual frameworks, discourses and decision- or, attheotherextreme, beradicallyemancipatoryinnature, chal- extreme, beconstrainedby‘politicallydefinedvisionsofthefuture’ can facilitateinnovationinpublicserviceswaysthatcan,atone in thepublicsector, Farr(2013)discusseshowcitizeninvolvement participation. Drawingonthisandherownempiricalcasestudies tive actionofcitizens/welfare serviceusers)modelsofuser driven bystateagendas)and‘democratic’(i.e.builtonthecollec- subtle formsofoppression andsocialexclusion. sion riskbeingdeployedsimplistically, thereby obfuscating more of service user empowerment and democratization of service provi - setting, theirconfigurationsandpossibleeffects, thediscourses respected autonomous persons.(2012: 509) of professionalspaternalism to more active, empowered and of usersfrom arole of passivity anddependenceonthe as an unalloyed good, because it represents a transformation couched byitsadvocatesasbeing ethicallystraightforward and … theshifttowards greater userinvolvementistypically In studyingthepowerdynamicsinvolvedinco-designwork, Beresford (2002)distinguishesbetweenthe‘managerialist’(i.e. Downloaded by [193.90.12.89] at 23:31 21 March 2016 tion betweenKentCountyCouncilandEngineServiceDesign; from thecollabora- SILK –SocialInnovationLabforKentborn forms ofcitizenparticipationinhealthcare design(seeforexample Social Innovation Labs be auseful model for bringing about new co-design worktobeinitiatedandmanagedbypatients?Or, would mean thatspacesand/ormechanismsshouldexistforhealthcare like. Forexample,wouldaredistribution ofdecision-makingpower begin tooutlinewhattransformedconfigurationsofpowermightlook services, itisimperative–ifweaimtoinfluencepracticethat of people’s (users,workers,citizens,publics)experiencesofpublic shifts ofpowerincollaborativeworkaimedatimproving thequality mental healthcare). Furthermore, inexamining thenetworksand analysis of powerand powerlessness in participatory practices in the contextofmentalhealthcare, orBroer etal,2014,forarecent a discussionoftheoriespowerandserviceuserempowermentin in Courpassonetal,2012;seealsoMastersonandOwen,2006,for power asinFoucault,1977,1980,1998;‘productive resistance’ as power and resistance (e.g. capillary power as opposed to sovereign to nameafew–andgrounded inmultilayered conceptualizations of ganizational science,participatoryactionresearch andanthropology tools ofdifferent traditionsandscholarships–sociology, design,or call forwouldneedtodrawupontheconceptualandmethodological retically richandalsodirectly relevant topractice,theanalyseswe and whatrole(s) theyallowfordesignexpertise.Inorder tobetheo- subject positioning,whattheirethicalandpoliticalimplicationsare cluded bycurrent practices,howthesepracticesaffect identitiesand questions suchaswhich‘publics’are beingengagedand/orex- critical approach topoweranditseffects thatcanilluminatecomplex services need–wesuggesttobeexaminedmore closelywitha and Gewirtz, 2012: 510). Current co-design practices forpublic the ethicalcomplexitiesembeddedinwelfare relationships’ (Cribb tively uncriticalreadings ofserviceuserengagement‘failtorepresent As theseauthorsgoontoillustrate,suchone-dimensionalandrela- the relationships ofpowerbetween citizensandpublic services. often acquire adistinctpoliticaldimensionbyseekingto re-configure the institutionalhealthcare setting,participatorydesign approaches both organizationalprocesses anddesignpractice.When appliedin tion of co-design in public services requires critical approaches to public services.We havearguedthattheadoptionand implementa- challenges thatco-designcan entailwhenusedinthecontextof and weaknessesoftheapproach andtohighlightinparticularthe aimed toprovide anoverview ofourunderstandingthestrengths Co-design approach tohealthcare qualityimprovement, wehave In illustratingtheprinciplesandpracticesofExperience-based Conclusions Malmö LivingLabsanddiscussedbyBjörgvinssonetal,2012)? the ‘agonistic democracy’ model implemented in Sweden through Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector 1 or -

243 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 244 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert Bratteteig, T. and Wagner, I.(2012). ‘Disentangling power and Bradwell, P. andMarr, S. (2008).MakingtheMostofCollaboration: S.,Mullin,B.andOld,A.(2012).‘ImprovingBoyd, H.,McKernon, Bowen, S.,McSeveny, K.,Lockley, E.,Wolstenholme, D., Cobb, M. Björgvinsson, E.,Ehn,P. andHillgren, P. A.(2012).‘Agonisticpartici Berkun, S.(2004).‘Programmers, designersandtheBrooklyn Bridge: Beresford, P. (2002).‘Participationandsocial policy:Transformation, Bate, P. andRobert,G.(2007b).‘Toward more user-centric OD Bate, P. and Robert,G.(2007a).BringingUserExperienceto Adams, M.,Maben,J.andRobert,G.(Forthcoming).Improving References 1. Note quality ofpatientcare. expertise within such processes and their eventual impact on the reconfigurations ofpower relations, theappropriate role ofdesign illuminate thepotentialofco-designpracticetobringaboutsuch We callforcriticallyorientedcross-disciplinary research efforts to

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245 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 246 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert Robertson, T. andSimonsen,J. (2013). ‘Participatorydesign:An Plsek, P. (2014).AcceleratingHealthcareTransformation withLean Piper, D.,Iedema,R.,Gray, J.,Verna, R.,Holmes,L.andManning, Moore, C.andBuchanan,D.(2013).‘Sweatthesmallstuff: Acase Meroni,. Farnham: A.andSangiorgi,D.(2011).DesignforServices Masterson, S.andOwen,(2006).‘Mentalhealthserviceuser’s Locock, L.,Robert,G.,Boaz,A.,Vougioukalou, S.,Shuldham,C., Lenihan, D.andBriggs,L.(2011).‘Co-design:Toward anewservice King’s Fund(2011).ThePatient-centredCareProject:Evaluation Iedema, R.,Merrick,E.,Piper, D.,Britton,K.,Gray, J.,Verma, R. Routledge, pp.1–17. Design.London:International Handbookof Participatory introduction’. InSimonsen,J.andRobertsonT. (eds),Routledge Illness. Oxford: Oxford UniversityPress. L. (eds), Understanding andUsing Experiences of Health and services’. InZiebland,S.,Calabrese, J.,Coulter, A.andLocock, using experience-basedco-design(EBCD)toimprove healthcare CRC Press. Robert, G. (2013). ‘Participatory action research: and Innovation:TheVirginia MasonExperience.BocaRaton,FL: ManagementResearch,25:162–172. Services New SouthWales publichospitals:Anevaluationstudy’.Health experience ofpatientsaccessingemergencydepartments in N. (2012). ‘Utilizing experience-based co-design to improve the acute care’.ManagementResearch,26:9–17. 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The JournalofAppliedBehavioralScience,46:73–91. in EmergencyHealthServices:TheArchitecture ofDeliberation’. and Manning,N.(2010).‘CodesigningasaDiscursivePractice Health Services and Delivery Research,2. andDelivery Health Services Downloaded by [193.90.12.89] at 23:31 21 March 2016 Tsianakas, V., Robert,G.,Maben,J.,Richardson, A.,Dale,C.and Thille, P., Ward, N.andRussell,G.(2014).‘Self-managementsupport Sinding, C.,Miller, P., Hudak,P., Keller-Olaman, S.andSussman, Sangiorgi, D.(2011).‘Transformative servicesandtransformation Sanders, E.B.N.andStappers,P. J.(2008).‘Co-creation andthe Salmon, P. andHall,G.M.(2003).‘Patientempowerment of healthcare research, policyandpractice. development andchangemanagement thatspansallthree domains large-scale change. He has an overarching interest in organization and serviceimprovement inhealthcare, andnewperspectiveson tional studies and organizational sociology and focuses on quality Professor Glenn Robert’s research draws on thefields of organiza- in twoExperience-basedCo-designprojects inthisfield. user involvementwithafocusoncancercare. Shehasbeeninvolved research onantenataldecision-makingandmore recently, onservice Dr Vicki Tsianakas isamedicalanthropologist. Shehascarriedout health servicesandsupportacross EnglandandWales. within theorganizationanditslocalbranches,whichprovide mental sponsible foraprogramme whichaimstoembedservicedesign Services StrategyandDevelopmentManagerforMind. She isre- and deliverservicesindifferent fields.Shecurrently worksasLocal ing withvoluntaryandcommunitysectororganizationstodesign Paola Pierrihastenyears’experienceinsocialinnovation,work- Experience-based Co-designinhealthcare. vice (re)design forqualityimprovement. Hercurrent workfocuseson practice, andserviceuserinvolvementindecision-makingser awareness inmedicaleducation,parents’ views ofhealthvisiting different dimensionsofperson-centred healthcare, includingcritical and medicalanthropology. Herresearch todatehasfocusedon Dr SaraDonettoisasocialscientistwithbackground inmedicine Author Biographies Experience-based Co-designandHealthcare Improvement: RealizingParticipatoryDesigninthePublicSector 20: 2639–2647. in breast andlungcancerservices’.SupportiveCareinCancer, Using experience-basedco-designtoimprove patientexperience T.Wiseman, (2012). ‘Implementing patient-centred cancer care: consequences’. SocialScience&Medicine,108:97–105. in primarycare: Enactments,disruptions,andconversational production ofhealthcare disparities’.Health,6:400–417. J. (2012).‘Oftimeandtroubles: Patientinvolvementandthe design’. InternationalJournalofDesign,5:29–40. new landscapesofdesign’.Co-Design,4:5–18. Social Science&Medicine,57:1969–1980. control: Apsychologicaldiscourseintheserviceofmedicine’. -

247 The Design Journal Downloaded by [193.90.12.89] at 23:31 21 March 2016 248 The Design Journal Sara Donetto, Paola Pierri, Vicki TsianakasSara Donetto,PaolaPierri,Vicki andGlennRobert Email: [email protected] Tel: +442078365454 Nursing andMidwifery, 57Waterloo Road,LondonSE18WA, UK. Innovation, King’s CollegeLondon,Florence NightingaleFacultyof Professor GlennRobert Email: [email protected] Tel: +442078365454 London SE18WA, UK. Nightingale Faculty ofNursing and Midwifery, 57Waterloo Road, Dr Vicki Tsianakas, Research Fellow, King’s CollegeLondon,Florence Email: [email protected] Tel: +442082152343 Mind, 15–19Broadway, Stratford, LondonE154BQ,UK. Paola Pierri,LocalServicesStrategyandDevelopmentManager, Email: [email protected] Tel: +442078365454 London SE18WA, UK. Nightingale Faculty ofNursing and Midwifery, 57Waterloo Road, Dr SaraDonetto,Research Fellow, King’s CollegeLondon,Florence Addresses forCorrespondence , Professor ofHealthcare Quality and