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as impersonal, standardised, and routine. The choices we make, every minute, every day, for every patient are ones that we know to be right but their logic or value is not perceivable to patients.

As designers of services, we must understand the system that the service supports and the behaviours it perpetuates. Often we must question that system as much as we reflect it. It is not sufficient to build a service that considers the end user experience but more one that exposes the system and makes it tangible, understood and accessible. Service design when done well focuses on giving the user power, control and influence. It offers options and choice by demystifying the systems and inviting the user to feel invested and engaged in its success. We have found that once a user understands the hidden drivers of healthcare services that are significantly more likely to act in concert with them.

In healthcare, the potential for an empowered and informed user to catapult

Designing for ConsequenceHow to plan for the enduring effect of design in complex systems

Though currently considered very different design arenas,

services are frequently the window into systems. When a

customer engages with a service, they are, in fact, being drawn

into the top layer of a system. Like a giant iceberg, the service is

what has been made visible, what can be known.

It is just a tiny fraction of a much more chaotic system hidden beneath the surface. This is never truer than when someone encounters healthcare services. They collide with a system so obscure, so daunting in its complexity that the experience itself can be disorienting at best but more typically, terrifying.

How they navigate the system is through the service cues we design. We allow them just a select glimpse of the whole, with the complexity hidden so as to not confuse the user. We design the access and influence points to direct and focus their involvement and to manage their inputs only where the system can tolerate them. In healthcare, this is done because the system has evolved to be simply too confusing to explain, and with this confusion comes increased volatility. Existing as two parallel universes, the needs of the system often contradict the needs of the user. In the healthcare system, we optimise to mitigate risk, to keep people safe. This can be experienced

Lorna Ross, a graduate of The Royal College of Art (London, England), has 24 years' experience in design, design research and innovation, with the past twelve years focused on health and healthcare. She is a strategic leader in directing the discovery and implementation of transformative, user-centric care models at the Mayo Clinic Center for Innovation.

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break for a reason, probably because they were not adding value and so the system is trying to rewrite the story without them in it. Take, for example, the patient who keeps turning up in the emergency department despite numerous directions to seek care services through their primary care clinic. Though considered a deviant in the eyes of the clinician, they are in fact a super-user of sorts. They have determined that the just-in-time services offered in an emergency department are significantly more compatible with their family’s unpredictable healthcare needs than the limited fixed hours of a clinic. When users forge new pathways in the system it is typically because they have figured out the most direct route to value for them.

the industry to new paradigms is so potent that the opportunity for service design is less a one of successful translation and more of radical adaptation. The design of compelling, meaningful and effective healthcare lie less in clever interfaces and tools to the existing system and more in allowing the user to determine through their actions where real value lies.

Design, like science, is a tool for understanding, as well as for acting. It offers us a process by which complex and confusing issues can be examined and considered from intersecting perspectives. Good design rarely focuses on fixing things, but rather more on transforming things. The subtle, but important, difference is that, in complex systems, most things

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most disturbing of all, at increased risk of error and burn-out.

I have recently been struck by how effectively service designers create maps (often giga-maps) and models of the system they are hoping to innovate, but when they move towards proposing solutions their thinking becomes less dynamic. It may be that the thinking and seeing tools we have developed are so comprehensive that they lay bare possibilities that our ‘doing’ tools do not know how to manage. To use a medical analogy, our treatment tools lack the precision and sophistication of our diagnostic tools.

I would pose the possibility that we should think about designing less for mitigating risk or managing uncertainty and more for having an enduring effect. We need to utilise our advanced skills in seeing cause and effect, not only when we study systems, but also when we attempt to transform them.

A designer’s systems view is less the discrete parts and more the dynamic relationships between them. When considering any action, you can estimate both the

If we want our service systems to succeed and scale we need to design for internal fragility, competition and obsolescence.

It has been an enduring experience of mine, consistent across the five innovation labs I have worked at, that the paralysing anxiety of managing risk while innovating complex systems, biases groups strongly to favour additive rather than subtractive concepts. Universally, there is greater tolerance for innovations that promote additional elements than those that challenge the value of existing ones. Complex systems grow increasingly complex simply because of the risk in destroying things. These systems tolerate huge redundancy and inefficiency to maintain the status quo.

No one knows this more than the nursing staff in our hospitals, burdened by the increasing demand for cus-tomised standardisation, transparency, customer service to compliment the more standard delivery of exceptional service outcomes, they find themselves crippled by the cumulative effect of trickle down service innovation and,

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benign experiment had a snowball effect that rippled through the entire care model. So much so that, when these mothers delivered, they were loath to engage with paediatric services as they, too, practiced a similarly institutionalised and professionalized infant care model. Having had the experience of control and autonomy, the patients were significantly more dissatisfied with the absence of this and became powerful advocates for reform. The impact and effect of this experiment was to activate the patient as change agent and allow for the implications of the concept to ripple out in a cascading series of triggers.

I would challenge the service design community to become less enamoured with our ‘seeing’ tools and work quickly to advance our expertise in the ‘doing’ or impact tools. In the future, as service and systems design become more complex, we will be asked to tackle greater and greater problems. We must understand how to design for effect, for enduring impact,for... consequence.

desired effect and also the indirect effects equally. Often, to effectively adjust dynamic systems, it is better to design for consequence, for a cascading impact, that for local or direct effect.

An example of this from our work at Mayo is an experiment that we ran with expectant mothers, where we gave them access to foetal heart rate monitors 24/7. This was framed to the OBGYN department as a simple efficiency in reducing the demand for reassurance, particularly during the final trimester. What it did, in fact, was to fundamentally challenge the existing care model where the tools resided with the institution and access to them constitutes the service. Here, the experiment of transferring the location of the tool in the system away from the clinician and to the patient was effective, not only in solving the immediate problem (demand for reassurance) but it more importantly had the consequence of triggering a fierce appetite in the patient population for more control. The overly medicalised and professionalised aspects of pre-natal care in low-risk pregnancy were called into question and a seemingly

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