Co-designing Employee-driven Service Development Instruments for Public Health Care

Co-designing Employee-driven Service Development Instruments for Public Health Care Katriina Lahtinen 1, Hanna Laalo 2, Valtteri Kaartemo 2, Marika Järvinen 3, Liisa Lumiaho 4 1 University of Jyväskylä, 2 University of Turku, 3 Pirkanmaa Hospital District, 4 Central Finland Health Care District The paper presents an action research on co-designing employee-driven service development instruments for public health care professionals. The empirical study examines how the methods and tools co-designed for service development with the workers could support employee-driven innovation initiatives in health care organizations, and strengthen the approach and emphasis on the discovery of unmet human needs in service development. Particularly, the research findings focus on how the co-designed instruments overcome the identified barriers for engaging health care professionals in employee-driven innovation processes. 1. Introduction Academic articles and mass media remind us frequently that health care is in crisis and that public health care is becoming too expensive (Kaplan; Porter, 2011). At the same time, the quality of health care should remain high with well-designed processes, committed patients and satisfied employees. To solve the crisis, public health care needs actions at both policy and grass-root levels. Part of the solution may be that employees take more initiative in developing more efficient processes and services. Over the recent years, we have witnessed a hike of interest in employee-driven innovation (Kesting; Ulhøi, 2010). Some of this attention has even focused on health care context (Knol; Van Linge, 2009; Tsai; Liou; Hsiao; Cheng, 2013; Åmo, 2006). Yet, we still lack understanding on how to engage public health care professionals to design services and to renew everyday work practices. Based on our experience in the field, there are typically some individuals who are interested in planning the processes but it is challenging to have larger scale participation in development activities in public health care organizations. Encouraging employee-driven innovation in public health care requires not only theory development in the field but practical solutions that are helpful for employees in renewing work practices. Our research is based on the research group's interest to combine entrepreneurial behaviour and innovation with design thinking to create new, flexible and rapid service development instruments in public health care. Particularly, we are interested in how to take the contextual restrictions of public health care organizations into account in developing practical tools and methods for 1

everyday innovation activity. In this paper, we present two service development instruments that were co-designed with health care professionals to enhance employee-driven innovations in public health care. They showcase instruments that overcome the constraints characteristic to the context. The co-designed instruments, the collective service development tool Idea Window and the customer participatory tool Travelling With Change, were created as a part of the service design oriented joint development in the project. We focus in our research paper on the discovery of new employee-driven service design instruments in everyday work for tackling the unknown customer needs, user understanding, tacit knowledge in work, hidden possibilities and initiatives in work context to be identified and clarified in service design, development and innovation processes. The study examines in particular how the methods and tools co-designed for service development with the workers could support employeedriven innovation initiatives in health care organizations, and strengthen the approach and emphasis on the discovery of unmet human needs in service development. The paper is organized as follows. First, we briefly introduce available literature on employee-driven innovations with a specific focus on the context of health care organizations. Second, we describe the methods for co-designing the employeedriven service development instruments, and the methods employed for data collection and analysis. Third, we discuss our research findings. We focus on the factors that encourage employees to participate in the design and use of service development instruments. Thus, we contribute to the literature by identifying employee rationale on how to engage health care professionals in employee-driven innovation processes. 2. Employee-driven innovations Innovation is a multidimensional process that covers various aspects of newness. It may refer to the development process with an outcome of new goods, services, marketing methods, or even organizational practices. Here, we do not approach innovations as commercial success stories. Instead, we refer to process innovations that are new ways of acting to diminish the cost or to increase the quality of health care services. This includes but is not limited to organizational innovations that are changes in the workplace practices to improve administrative efficiency. Innovations may origin from 1) actors and other sources external to the organization, or 2) the internal actors, such as R&D staff and other employees (Cassiman; Veugelers, 2006). In this paper, we focus on the latter source of innovations. To be precise, we are interested in employee-driven innovations (EDI). EDI refers to the exploration and exploitation of new processes and work practices that originate from a single employee or a group of employees to whom innovation development is not a part of job description (Kesting; Ulhøi, 2010). In EDI literature, it is considered that ideas how to improve processes and work practices stem from ordinary employees. In other words, internal innovation development is not only for the designated R&D people. In fact, research findings support EDI, as evidence 2

shows that it is beneficial to engage ordinary employees in service development processes. However, it is also outlined that ungoverned participation is counterproductive. (Kesting; Ulhøi, 2010.) Engagement of health care professionals in innovation processes has also been requested by both public health care organizations as well as professionals. Research findings by Oecon (2006) indicate that health care professionals do not perceive to have equal opportunities to participate in innovation processes. Particularly, staff in the lower ranks perceives that it is not suitable to enact innovative role at the workplace. Therefore, there is a need to empower the staff to engage in innovative activities. In addition to structural empowerment which refers to power based on the employee s position in the organization, there needs to be psychological empowerment for the staff in the lower ranks (Knol; Van Linge, 2009). Psychological empowerment refers to the fundamental personal convictions that employees have about their role in the organization. As Tsai et al. (2013) have found, worksite support can support psychological empowerment. This support takes into account open communication systems which empowers employees and engages them in decision-making and EDI processes (Fees; Taherizadeh, 2012). Thus, management of health care organizations can create a supportive worksite where creative nurses are more likely to work and get engaged in development (Tsai et al., 2013). These findings are in line with the study by Wihlman; Hoppe; Wihlman; Sandmark, 2014) in the context of Swedish welfare services. Their research identified three main themes to support EDI, namely support (including leadership and innovation processes), development (including creativity and learning), and organizational culture (including attitudes and communication). In addition, it has been proposed that employees require incentives for engaging in EDI (Kesting; Ulhøi, 2010). This proposition is supported by evidence on rewards systems boosting creative activities in commercial organizations (Gupta; Singhal, 1993). In brief, public health care organizations need to create the right conditions to improve empowerment of health care professionals. However, the creation of beneficial conditions is not always easy, as there are barriers for engaging in service development activities in health care organizations. For instance, Wihlman et al. (2014) have found that unclear or non-existing innovation processes with ambiguous goals, insufficient learning, and deficient organizational slack, attitudes of colleagues and lack of communication hinder the likelihood of innovation activities in welfare services. To synthesize, the research indicates that EDI requires instruments that help in structuring the service development process. The practical tools and methods need to provide psychological empowerment and incentives to those in lower ranks in the health care organization. In addition, the instruments must encourage positive support to development activities and enhance open communication. These insights were taken into account in the action research project that focused on co-designing employee-driven service development instruments for health care professionals. We present the action research and the results in the following chapters. 3

3. Empirical study In the action research project we co-designed two employee-driven service development instruments. Our aim was to create instruments which would help in overcoming the typical constraints in EDI in health care context. 3.1. Action research The empirical study is based on a multidisciplinary action research project realized in two large public sector health care organisations in Finland. Two project case studies were realized in the Pirkanmaa Hospital District and in the Central Finland Health Care District. During the project, the project team co-operated with the health care professionals for creating new tools and methods for developing services in the context of everyday work practice. The co-operation was based on service design methodology and design thinking which were partly known and applied in cooperating organisations. Co-designing service development instruments and test-using them with employees is a good approach to engage working community gradually and pragmatically in design thinking. Design thinking taps into capacities we all have but that are overlooked by more conventional problem-solving; it focuses on creating products and services in process which is deeply human (Brown; Wyatt, 2007). Design thinking relies on our abilities to be intuitive, to recognize patterns, to construct ideas that have emotional meaning as well as being functional (ibid.). The designers in the project were facilitators helping the employees in the cooperating organisations to meet a need for service development but also to communicate and to externalise ideas in a way that others (especially nondesigners) can understand and so enable discourse and debate (Koskinen; Zimmerman; Binder; Redstrom; Wensween, 2011, 125). The instruments were eventually created by group working which is a fundamental part of the service designer s function in any organisation given the multidisciplinary nature of the field (Callaghan 2009). The dialogue was facilitated through the creation and discussions initiated from ideation and use of instruments. Instruments developed in the project were utilized as situated design methods to support employees ability to better understand processes and to identify opportunities for learning, developing and renewal in different situations in one s own work and work community and this way to enhance change (Simonsen; Bærenhold; Büscher; Scheuer, 2010). The aim is hence, as Schön (1983, 68) describes it, that The practitioner allows himself to experience surprise, puzzlement, or confusion in a situation which he finds uncertain or unique. He reflects on the phenomenon before him, and on the prior understandings which have been implicit in his behaviour. He carries out an experiment which serves to generate both a new understanding of the phenomenon and a change in the situation. The two cases shared the context of public health care. However, they were different in terms of aim and approach of the co-designing process. In the first case 4

(Pirkanmaa Hospital District) employees co-designed service by collectively observing customers without engaging customers in the actual design process. In the second case (Central Finland Health Care District), the instrument was designed for the employees but the actual content was mostly generated in the intensive collaboration with the customers. This enabled stronger focus on the customer viewpoint, whereas in the first case the focus was more on developing processes from the perspective of own tasks as well as customer benefits. These case studies are described in detail in the following. 3.1.1. Case Study of the Tampere University Hospital; Pirkanmaa Hospital District, Tampere Finland In the Tampere University Hospital action research project was realized in close cooperation with the Department of Customer Services and its Customer Service Development Manager. The manager has successfully applied service design many years in different clinics in the hospital. The result of her team's work is encouraging and a good starting point for the project. The department operates with dozens of active and heterogeneous cases. A great number of health care professionals has been time consuming but has also generated plenty of content for further development activities. The good work has caused a positive problem for the development team; service design is evidently useful and effective method to develop services but application of service design on a larger scale in the hospital requires new ways, tools and methods to inspire and engage personnel to participate in service development. Therefore, new tools and methods would be one way to apply service design in a variety of services and service development challenges, and to get health care professionals involved in development of new service solutions and in dissemination of the best practices and experiments. The project design team analysed the situation with the development manager and had together an idea of a participatory service development tool that could be codesigned and prototyped with the group of employees in a brief experiment in spring 2014. The processes had been initiated in the case organizations before the designers stepped in. Therefore, the basis for the implementation of the service design tool had already been built. Anyway, in busy environments such as hospitals, it is difficult to get people to break away from the everyday work and to engage in a variety of development challenges, so one of the key features of the tool would be that it helps to see the work in everyday life from the perspective of the service development, and to realize the things that can be solved quickly and nimbly in normal work. Thus, the tool should function in daily work and strengthen employees' sense of initiative and activity. It also should help employees to detect the invisible side of the work, which affects the every day services and the quality of them. It should help in facilitating employees to observe and to record their experiences and ideas relating to services, and to pay attention to the customer's service experience and behaviour. Tackling the unknown customer needs, user understanding, tacit knowledge in work, hidden possibilities and initiatives in work context would be identified more systematically by the tool. The data collected by the tool would be analysed and clarified together in workshops and used for customer service development. 5

Idea Window Idea of employee-driven service development tool was matured in collaboration into a tool called Idea Window. The first version of the Idea Window was co-designed in close co-operation with the group of personnel of three clinics in the hospital. The Idea Window was designed to be easy-to-use touch screen computer with simple user functions on the graphical user interface which would be easy to find and available all the time. It was designed as a platform for workers findings, initiatives, ideas and solution proposals to develop services. In the Idea Window, employees can enter their observations and ideas on the screen In addition, an employee can propose solutions and experiments related to the findings and observations of the service experience. All the items can be combined together to form a variety of topic clusters on the screen. Employees can modify and store the clusters in the user interface according to what is meaningful to them. Any employee can anonymously leave a proposal in the Idea Window and read and move the items on the screen. The Idea Window was designed to put the patient at the service path clearly visible and to open the view into the customer s service experience. The material produced by the personnel was ground for joint development workshops and utilizable material in service design. In each clinic, two touch screen computers were located in central locations. The Idea Window was used for three weeks in each three clinics that participated in the project. Figure 1. The Idea Window in use in the Tampere University Hospital. Photo by Minna Tuominen, Pirkanmaa Hospital District, 2014. During the Idea Window experiment, the personnel produced 75 ideas and comments related to patients' service experiences, 38 proposals for solutions and improving services and 4 proposals for experimentations. The material produced within Idea Window was analysed in two workshops with the group of personnel. 6

Nurses, doctors and couple of members of the hospital administration found the data really revealing and were motivated to use Idea Window during longer time and for different purposes. The customer service unit and the administration representatives evaluated the Idea Window useful on a larger scale if some small changes were made to the interface. The nurses evaluated the Idea Window suiting well to everyday context. It was really important to them that ideation and customer experience observing tools are available all the time and thus are maintaining the customer focus in the service. 3.1.2. Case Study of the Unit of General Practice, Central Finland Health Care District, Jyväskylä Finland The second research case was actualized in co-operation with the Central Finland Health Care District and more specifically with the Unit of General Practice. The unit had developed a group-based approach to support and guide people who have problems and changes in their health. The service model of the Lifestyle Change Groups (LSC-groups) was developed by the small group of health care professionals in the Central Finland Health Care District as a solution for a need to provide health guidance and support in more collective and interactive ways. The LSC-group activities are organised together by the health care district and the primary care. Also, health care professionals in other parts of Finland have been interested in organizing similar kinds of group meeting activities for customers in health care. The project team met the LSC-group developers in joint planning workshops in the spring 2013 and together they made a preliminary plan for a series of experiments that could bring some new elements in developing group mentoring. Through participatory workshops and idea sessions the group leaders and developers wanted to form more comprehensive understanding of their customers needs and life situations to design more interactive service. The service providers (i.e. the group developers and supervisors) had a shared view that good results of the service were due to the trust and transparency clearly apparent in group meetings but never been a specific point in development of the service. Inspired by the review of service design by the research the group organisers wanted to apply service design methods for gathering more information on the members of the LSC-groups and to process the information more consciously with the participants. Travelling With Change During the research project the LSC-group developers and leaders designed a printed material package called Travelling With Change. The first plan of the material was to make a guide or a book for LSC-group members, which, however, turned in co-design process into a collection of cards and posters that could function as a dialogic and interpretive situation mapping tool between LSC-group members and supervisors. The collection of the material was designed to be modular and thus versatile to use in the group meetings and outside of them. The project team was actively involved in material planning and implementation. The Travelling With Change material contains a variety of tasks and ideas for supporting the group members processing and reflecting their life with the change they have faced. The theoretical framework of the intervention was developed using elements of several theories in health promotion. One is Transtheoretical model, which begins with identifying group members readiness for lifestyle change. The 7

model also incorporated Social-cognitive theory, Self-regulation theories and motivational interviewing. In the intervention, these theories guide the concrete tasks in customer encounters. (Abraham; Michie, 2008; Prochaska; Redding; Evers, 1997; Prochaska; Velicer, 1997; Michie et al., 2009.) The content does not actually give instructions, but rather evokes group members to think about their individual life and wellbeing from more holistic perspective. The first version of the modular material was a poster with the view of sea in which the user can draw and write down thoughts and experiences related to tasks on the poster (Fig. 2). That version turned out to be effective particularly in opening discussion in meetings and enabling collective review on group members different life situations and styles. It directed the service development focus on customer s value creation. The layout and the content of the poster were changed after the first two months experiment. The later version of the material was designed to be a collection of cards and posters, so that it could be used more flexibly and selectively. The posters were still intended to use in joint discussions in the groups. The cards visually matched with the posters (Fig. 3) were clearer and more concise in content. Figure 2. The poster was actively used in the beginning of the meeting for starting the discussion and for gathering customer information. 8

Figure 3. The new format of the Travelling With Change material was the result of a multi-stage design and experiment. During the case study of the LSC-groups, 10 workshops were organised. Seven workshops were for health care professionals working as developers or supervisors of the groups, 3 workshops were directed to users. Co-design process with research team members was documented in written memos and partially in video format. The user targeted material package was changed twice during the project. Format changed on the basis of two user participatory test periods. The last version of the Travelling With Change package including cards and posters has received very positive feedback from the group supervisors who have not been involved in the design process. The material is considered as a tool to better align service to different user needs and situations. The form of the package is modular and thus suited for use in both in the group meetings and in privacy. 3.2. Data collection and analysis Our study builds on field notes and video material from the co-design workshops as well as interviews with healthcare professionals in the participating organisations. Further, written reflections of employees experiences about the developing are utilized as research material. 9

Data collected at the Tampere University Hospital consists of interviews with healthcare professionals. At this case organization, attendees were also asked, both in the beginning and in the end of the project, to literally reflect their experiences about the project and the tools used, and to generally describe their thoughts about developing and creating new ideas in their work community. The analysis of video material and field notes collected at the Unit of General Practice in the Central Finland Health Care District is also described for the purpose of this paper. The data collected at the Tampere University Hospital was analysed by identifying themes that respondents brought up when describing their views and experiences about the development project. All the material was transcribed, read and coded carefully according to emerging topics. After this, the topics were categorized under different themes. In the analysis attention was paid especially on how health care workers experience the type of co-developing used in the project, and what are the preconditions required to support motivation towards EDI. In the analysis of video material and field notes collected at the workshops organized at the Unit of General Practice in the Central Finland Health Care District the focus was on identifying central themes that were brought up in the co-ideation process when developing the Travelling with Change material package. Here attention was paid on the process of co-designing. Based on the data and analysis of both cases we identified central experienced benefits of employee-driven service development instruments. These are presented in the following chapter. 4. Experienced benefits of employee-driven service development In this chapter findings considering employees experiences about employee-driven service development instruments are presented. The results are summarized in Figure 4. Particularly, we highlight the importance of open communication, meaningful development, and grass-root level development. 10

Figure 4. Experienced benefits of employee-driven service development instruments. 4.1. Development through open communication Respondents brought up the benefits for communication that the new development tools involved. In the respondents speech open communication is in fact depicted as a key factor in changing the practices of work community. It was found important that the tools used in the project opened up possibilities to anyone in the work community, regardless of one s role or status, to anonymously present their thoughts. The Idea Window also appeared to be a practical tool to make ideas visible and to store them. Collecting the ideas made the ideation more transparent and concrete, which was seen beneficial in the hectic reality of a hospital organization where new ideas are often born along with the work and soon forgotten. Idea window has made it easier for people to bring up their thoughts/suggestions for renewal. When problems are visible to everyone there will be more suggestions for improvement and people more responsively tell about their thoughts when you have the possibility to anonymously propose ideas. (written answer, nurse 5) [ ]And the best thing is that it s anonymous. So anyone had the opportunity to put their thoughts there and when you received a message from a patient it was brought there directly, and it s not just forgotten, we discuss about it, it s written down. (interview, nurse 1) 11

There s a lower verge to go to write when there are no names. (interview, nurse 3) Not only was the Idea Window appraised as a one-way channel to express and share ones thoughts but it was also seen as a facilitator of interaction among employees. The opportunity to comment ideas presented by others and to make suggestions for developing them further opened up new possibilities for communication free from time restrictions caused by hectic reality in hospital or different shifts at work. Through idea window I understood things that I sometimes think about but I haven t realized that others think about the same things. I just never haven t mentioned about some things. Others might have a solution which you can t figure out by yourself. (written answer, nurse 4) [In idea window] Feedback comes so fast and it s possible to fast react. And it s open to everyone. Everyone can see it and it feeds itself -- it brings discussion at best. (interview, doctor 2) Each made it [wrote ideas] when they found the time. You didn t have to write anything, you could read, you could make suggestions. So in that sense it was very good that it wasn t scheduled to some specific time it was always there. And you could go there when you felt like you have time. When the idea came up you wrote it and when something came from the patients you just went fast to write. (interview, nurse 1) The trial didn t take time from patient work but instead each made suggestions when they had the time and when they felt like it. (written answer, nurse 1) Open communication turned out to be experienced as a key component of successful developing also among LSC-groups. The co-designed instrument was to complete the existing set of supporting material in a good way, strengthening empathic interaction between the group members and supervisors, opening a new channel for sharing the observations and findings, gathering and visualizing customer experiences and situations, and lowering the threshold to participate in the joint development. The LSC-groups in Central Finland Health Care District are co-created in collaboration with supervisors and developers. The developers have designed a rich set of supporting material, which is actively utilized in the groups. The material includes instructions, recommendations and hints for lifestyle change, and most are related directly to health promotion. The set is constantly revised. As a result, the supervisors receive a package with which it is relatively easy to launch new LSCgroups. In our research project developers were willing to experiment which kind of material they could co-design with the supervisors by bringing a group member and his or her experience and activities as the starting point for the development of the group activities. The aim was to create empathic interaction between the developers, supervisors and the users. The co-designed instrument was supposed to increase the real-life interaction between the employees and the customers. As one of the developers said We may have too high-level ideas, where the customer s everyday experience is. (video, developer 1) 12

The developers and supervisors of the LSC-groups created Travelling With Change package to support co-operation process. Material was designed together with the group members to enhance the collection of different life stories and experiences. The aim was to increase the engagement of the members with the group and with their own lifestyle change. However, Travelling With Change package was also designed to support the work of the supervisors and developers. With the help of the material it is easier for them to follow the progress of the group members and their experiences of the group in its different phases and thus share observations. In the best-case scenario Travelling With Change material collects and visualizes the customer experiences and situations. By evoking new thoughts and different interpretations the material may lower the threshold in taking up more sensitive personal issues in the group. Material was designed as visual as possible so that textual content and complexity was reduced to its minimum so that the material would not feel too overwhelming and would lower the threshold to participate in the discussion. The flexibility and modularity of the system is also perceived as a way to increase open communication within the groups as well as in the LSC-group development activities. A collection of cards was perceived as a natural format of the material for many employees. If it were a starting picture that could be changed. Why not a collection of cards that could be used in different ways [ ] Cards could be used in the group and alone. (video, developer 3) 4.2. Meaningful development When describing their experiences about various development projects respondents expressed strong frustration in the kind of developing in which the meaning was not clear for them. In these projects, it is difficult to find incentives for participating in development activities. If the connection to practices is seen weak not much value is given to the project, rather it is experienced as useless extra work. If it [developmental project] requires a lot of extra thinking or if it has not been presented clearly to us or if the point and benefits have not been marketed well to us -- then you react to it in a more aloof manner. (interview, nurse 2) Developing is experienced as important and meaningful if it is connected to the everyday practices in one s own work and if the improvements are visible or highly probable. To get motivated, clarifying the link to practice seems evitable. This viewpoint was strongly emphasized especially among nurses. From this point of view developing is not successful if it is too far from the practices. That you think too scientifically without facing the patient. (interview, nurse 1) What was brought up several times by the respondents when reflecting their experiences about the project was that the project especially directed one to think about the actions even more strongly from patients point of view. In evaluating the importance of developmental actions what counts most are the benefits they might produce to patients. Patients viewpoint is an important source of motivation and a central point in legitimating developing both among nurses and doctors. 13

The targets of our work are patients, and their good care is the motivation why you do this work. (written answer, doctor 1) You always think about the patient s viewpoint but maybe along with this project you really stopped to think about their experience. (interview, doctor 1) [After the project] you pay attention to the patient s viewpoint more. (interview, nurse 1) The LSC-group supervisors (nurses) felt that customer encounter is often challenging. The customer can avoid of talking the actual issue by talking around. Identifying of customer's actual situation and needs would require a number of individual meetings and much discussion. The group members are a mixture of people who have multiple problems with health and life situation. The employees try to find the ways to support both the people who are really trying to make a change in their life and the people who are just adapting to a new situation. There are so many this kind of people who live their life through other people. This type is very common in the groups. (video, developer 1) It would take perhaps several moments that she [patient] gets to the point. She must tell two or three times what her daughter or husband has eaten, or how her children eat and move. Before you get there, to her, who has come to the reception. (video, supervisor 1) The group consists also of people who have newly received a diagnosis. These people I experience extremely difficult from the steering point of view. One may process the adaptation to the new situation. It would be better for that person to get adaptation training and not to join the lifestyle change group. This relates to the allocation [of service or guidance]. (video, developer 3) In one workshop, the developers and supervisors of the LSC-groups agreed on that the lifestyle change support material should help group members to mirror their life situations in relation to their personal history and social networks. The health care professionals often have to open very challenging and sensitive topics in discussion with the patient and according to the LSC-group professionals it is one of the key factors to achieve positive results with the patient. Therefore, the careful and comprehensive study of the patient is one of the main conditions to provide good service. In the LSC-groups, the initial situation is also often difficult because the group members do not usually have clear thought of their situation or view of the target. Thus, the material package should function as an initiator and amplifier helping group members to frame and review their situations privately but also in the group meetings with the health care professionals. Now, it is tempting to say that this is one important question in our self-help book [LSC-group support material] context - mirroring own life to the very own family background. Somehow I feel that this will be extremely relevant in this case. (video, developer 2) 14

Target may not be clear. Maybe they haven t internalized their own targets. (video, developer 1) Tools would give that person an opportunity to begin to consciously seek change and to go towards the new. (video, developer 1) Material can tingle a little bit, just positively, so that a person learns to identify his own special features and strengths. (video, developer 3) 4.3. Grass-root level development Related to the experiences of meaningful development, respondents find important the kind of developmental actions that are realized on grass-root level and in close co-operation with those who do the work in practice. Challenges for motivation seem to occur if the ideas for developing come from outside or top-down, without concretely understanding the grass-root level reality. When employees can themselves think about suggestions for how to correct things, these [ideas] are tested more bravely. (written answer, nurse 1) There exists excitement in the work community to develop, people just need to be asked and they must be participated. (written answer, doctor 3) Ideas of participating, co-designing and entrepreneurial way of acting (intrapreneurship) were fundamental starting points in our research. This concrete doing from real needs of the workers and patients, and the aim to empower the grass-root level professionals can be seen as key points that made people at the case organizations participate in and get excited about the project. The best ideas come from those who physically work in the centre of where things happen, from midwives in this case. I think not many doctors put their ideas there [to idea window] (more distant relationship to practices?).-- I find it extremely important that actions are developed in co-operation with those who concretely do the work, perhaps together with those who ve got the tools. (written answer, doctor 1) This is how it [developing] should be, that it s targeted to us, that you act on the field so clearly. (interview, nurse 3) Now there are more and more these [projects] that nurses start to develop or nurses and doctors in pairs develop. In this way it s clearly more holistic. -- When the suggestions to change come from ourselves and not from what the administration says they are certainly much easier to accept. (interview, nurse 1) As in hierarchic hospital organisations major changes are very slow to realize, our project aimed at bringing attention to the small acts and achievements in every day work. Identifying new opportunities in the working environment and community was facilitated with the developmental tools. 15

It is easier to bring up ideas/problems/solutions via idea window. If the solution is the kind that it doesn t require organizational or structural changes it is easier to take forward. But if some bigger changes are needed it hardly happens. (written answer, nurse 4) Respondents reported that the Idea Window had produced small, concrete improvements in everyday work that were realized already during the project. For instance, handrails at the patients toilet been long missed were finally acquired, and the medicine cabinet was re-situated to better serve everyday actions and without disturbing patient operations. One example of the proposed solutions was based on the observation in which the patient had to wait twice to meet both the nurse and the doctor during the same visit. In the Idea Window, this observation generated the proposal in which all patients should go systematically first to the nurse and move flexibly from there to the doctor. These examples show how even the simple solutions can open a way to reduce patients' frustration and to incrementally improve the quality of service. The employees themselves can take many practical solutions that are relevant for the development of services and gradually get engaged in also more complicated service development. However, respondents clearly experienced that concrete changes were still to come. They found it to be too early to evaluate which of the ideas would be implemented, when, how or by whom. In the case study of the Life Style Change groups, the data generated in user participatory workshops stimulated the group leaders and developers to think their attitudes toward work. They noted that it is important that employees are able to apply large amount of knowledge and skills in work but they also should have a profound customer insight and possibilities to participate in modifying and designing service offering on grass-root level. Getting to know customer's ideas and needs can be a good way to strengthen understanding of what is the core of the service, and which parts of the service can be changeable and customizable. The group developers and supervisors wanted the Travelling With Change material to be a collection of relatively simple tools and instructions, but including also own thinking reviving tasks. They began to see the material as a tool or instrument that allows members and instructors of the group to shape the service together without losing sight of the central content and objectives. For us professionals it is typical that we harvest all the knowledge when we meet the customer. The customer's experience, however, is that it really wants simple things. The story plot is there that a person can get closer to the new over and over again through the simple things. I will say, the more I have made this group activity work, the simpler I would like to modify the body of the service. We have tried this, yes, but in reality things are rambling too much in all groups. (video, developer 2) 16

5. Conclusion and discussion: Preconditions for engaging health care professionals in employeedriven service development In this study, we showcase two service development instruments that were codesigned in two large public health care organizations. The initial aim and approach in the two projects were slightly different. Nevertheless, in both cases the development of the instrument enabled open communication, meaningful development, and grass-root level development. These features are important in a service development instrument in order to ensure EDI in the context of public health care. In both cases, co-designing a tool seemed to be a suitable and practical starting point to get employees interested in collaboration and to participate actively in project representing a totally foreign way of thinking and action. The Idea Window experiment enhanced employees to pay attention to full complexity of service development. On one hand, it highlighted the service implementation and performance as important part of the service development, on the other hand it stimulated ideation and quick testing of services during their everyday work practices. Typically, service development involves certain stages from ideation to implementation and testing, each of which has its own time and place in the process. In the Idea Window instrument different service development stages are roughly apparent and neglected to each other in one flexible open communication tool used for gathering information on customer, ideating new service solutions, making quick and simple experiments for service improvements and for monitoring impacts of new solutions in everyday work context. The Idea Window can be helpful in enquiring knowledge and experiences on new opportunities and ideas more comprehensively and participatory. It can be used for gathering broader and deeper information on the customer behaviour and values, and thus producing a good starting point for employee-driven service development in such hectic and very much routine-based working environment as hospitals. The Idea Window experiment revealed that co-designing developmental instruments with employees to encourage and to stimulate them in their developmental purposes can help the organization getting beyond the assumptions that block effective and new solutions. Co-designing instruments for collegiate use provides employees a lens to consider their work site and practices from more developmental aspect. They focus on designing an instrument, which should match with their work context and be usable in practice but simultaneously bringing out and triggering variable reforming aspects and efforts of the working community. When designing a developmental tool for their own use, at the same time, they reflect and process their working practices, attitudes, meanings and conditions from multi-dimensional point of view. Employees reflective process combined with customer information enquiry and analysis creates a very good base for renewing organisation more service-oriented. In co-designing the Travelling With Change package the employees clearly understood the importance of customer information as a central element in development of the service and were interested in co-designing method or instrument to enable more open and continuous dialog with their customers. The developers of the LSC-groups were motivated to form profound understanding of 17

customer processes and to design methods and tools for increasing customer interactions and strengthen supervisors enthusiasm for the joint development. The Idea Window and the Travelling With Change instruments seemed to help employees in recognizing the design and development process as a combination of overlapping phases of inspiration, ideation and implementation. Brown and Wyatt (2007) have called them as overlapping spaces of design thinking process. Rather than preparing a sequence of orderly steps in development process both instruments called the spaces of design in flexible, creative and collective communication and development process taking place in everyday work. As Brown and Wyatt (2007) have noted, design thinking can feel chaotic for the first time but the process makes sense and achieves results, even though it differs from the typical linear and milestone-based processes. The approach based on EDI and design thinking was applied in a unique way in our project to facilitate EDI in health care sector. Service development tools and methods tested in the case organizations brought attention to the expertise and capabilities of health care professionals as a source of renewal and change. We believe that the same approach and tools could well be applied also in other contexts and more widely in different sectors. As a theoretical contribution, the action research indicates that health care professionals are motivated to participate in designing and using service development (i.e. service design) tools and methods if the process is based on meaningful and practical frames which matter to health care professionals, if the process fits with contextual restrictions of healthcare organisation, and if employees have possibilities to modify the process and monitor the impacts and to apply the results in multiple ways. Our project facilitated the ideation in health care organizations to enable rapid development of services. However, there seems to be a gap between the creation and implementation of the ideas. Although some of the shared ideas were implemented already during the project, respondents found it difficult to see how most of the new ideas would be implemented in the future. As one of our respondents put it: The problem is often implementation, there are no resources/it s difficult to implement and so on. You can create ideas but it s more difficult to take them to practice level. (written answer, nurse 3). Also, what was not spoken about was who would be responsible for bringing new ideas into action. Based on our perceptions we claim that rapid and more flexible tools and methods are needed for evaluating the ideas to enable faster reacting and implementation. There exists a research gap and need for further research in this area of study although for instance transformative service research literature has increasingly started to pay attention to the issue. In the research paper, we focus on presenting and analysing the project results which open up new possibilities for more user-centric, employee-initiated, agile health service development and innovation processes in the context of everyday 18

work practice of health sector. We combine the development needs from EDI literature with design thinking orientation in our action research project. Consequently, we discuss the insights for preconditions to engaging health care professionals in employee-driven service development. Co-designing tools and methods with health care professionals is a way to engage healthcare professionals in the service development domain and to support their opportunity identification capability and initiative in service development. Thus, co-designing service development instruments may provide psychological empowerment for nurses in the lower ranks of health care hierarchy. Our research findings are in line with prior research on EDI in health care organizations. However, more research is needed on improving the incentive system, and the evaluation processes with the co-designed service development instruments. In addition to practical service design this also calls more empirical work on understanding what motivates health care professionals to engage in EDI and what kind of evaluation systems would encourage EDI in the context of public health care. Particularly, our study encourages finding how to design service development instruments that enable open communication, how to evaluate meaningfulness of initiated service development processes, and how to ensure grass-root level development. Based on our study and experience in the field, these are important questions particularly in the context of public health care. To advance our knowledge, we simultaneously call for more related research also in other contexts. References Abraham, C.; Michie, S. (2008): A taxonomy of behavior change techniques used in interventions. Health psychology 27(3), pp. 379-87. Brown, T.; Wyatt, J. (2010): Design Thinking for Social Innovation. Stanford Social Innovation Review, Winter 30-35. Callaghan, E. (2009): Personalities of Design Thinking. Design Management Journal 4, pp. 20-32. Cassiman, B.; Veugelers, R. (2006): In search of complementarity in innovation strategy: internal R&D and external knowledge acquisition. Management Science 52(1), pp. 68 82. Fees, W.; Taherizadeh, A. H. (2012): Exploring the Employee-Driven Innovation Concept by Comparing Innovation Capability Management Among Germand and Chinese Firms. In S. Høyrup, M. Bonnafous-Boucher, C. Hasse, M. Lotz, & K. Møller (Eds.), Employee-Driven Innovation: A New Approach. New York, NY: Palgrave Macmillan. Gupta, A. K.; Singhal, A. (1993): Managing Human-Resources for Innovation and Creativity. Research Technology Management 36, pp. 41 48. 19