Balancing a seesaw – leaders perspectives on design and traditional quality improvement in healthcare

Abstract

Purpose

The purpose of this paper is to explore and describe the perspectives and reasoning of senior development leaders in healthcare organizations, when reflecting on design as theory and practice in relation to more traditional methods and tools for improving quality and support innovation.

Design/methodology/approach

The paper is based on a qualitative interview design with five development and innovation leaders from separate healthcare regions in Sweden. They have, to varying degrees, applied design theory and practice for quality improvement and innovation in their organizations. The interview transcript was analysed using a content analysis together with an interpretive approach.

Findings

The major findings are to be found in the balancing act for leadership and organizations in healthcare when it comes to introducing and combining different theories and practices for improving quality and support innovation. The balance is between the change in power dynamics and pushing traditional boundaries in a complex healthcare world.

Practical implications

The narratives from the leaders' experience of applying design theory and practice for improving healthcare quality can help us create readiness and knowledge about how we prevent and/or facilitate planning and implementing design theories, practices, methods and tools in a healthcare context.

Originality/value

The study provides a unique insight when it captures and illustrates five different organizations' experiences when applying design for developing healthcare quality.

Citation

Boström, J., Hillborg, H. and Lilja, J. (2023), "Balancing a seesaw – leaders perspectives on design and traditional quality improvement in healthcare", The TQM Journal, Vol. 35 No. 9, pp. 173-190. https://doi.org/10.1108/TQM-07-2022-0219

Introduction

Healthcare institutions in the Western world have a long history in which the major focus has been on developing quality and patient safety regarding processes for acute and episodic illness. A systemic change towards a more person-centred approach is believed to benefit service users, healthcare professionals and the system more broadly, such as, for example, to also handle long-term, fluctuating needs of people with chronic conditions (Nolte et al., 2020). Balancing increased consumer expectations on healthcare along with technological advances on one side with scarce financial as well as personnel resources on the other side is, however, a major challenge (World Economic Forum, 2019). New illnesses of the body and mind combined with the technological revolution confronting an old system demands us to think again according to Cottam (2020).

The Swedish healthcare system has since around 2015, in different ways, developed strategies to deliver more person-centred care. The Swedish Association of Local Authorities and Regions (SALAR) has both been pushing as well as supporting this movement. Along with this, the patient act (Patient Act, 2014) was elaborated to strengthen and clarify the patient's position and to promote the patient's integrity, self-determination and participation. Another initiative for change aligned to this was the governmental initiative Nära Vård in 2018, to aim for a “a good, close and coordinated care that strengthens health, that the patient is involved based on their conditions and preferences and that healthcare resources are used more efficiently” (Swedish Agency for Health and Care Services Analysis [Vård-och omsorgsanalys], 2021:8, p. 19). However, the movement towards a more person-centred and close care have more to prove according to Vård-och omsorgsanalys (2021:8). They also stress the problem that healthcare organizations are not prepared for development initiatives and lack, not only sufficient participation from users, but also the learning between different actors and the prerequisites for successful implementation (Vård-och omsorgsanalys, 2018a).

According to SALAR (2022), the transformational change towards a more person-centred and integrated care [Nära Vård] is to be considered a complex phenomenon and complex challenges are characterized by low consensus, high unpredictability and with nonlinear dynamics (Stacey and Griffin, 2006). The transformational change of Nära Vård has four perspectives.

1. From focus on organization to person and relation;

2. From citizen and patients as passive recipients of care to active co-creators;

3. From isolated health and care interventions to coordination based on the person's focus; and

4. From reactive to proactive and health-preventive (SALAR, 2022).

Other studies (Andersson, 2015; Alvesson and Cizinsky, 2018; Eriksson and Müllern, 2017; Hudelson et al., 2008) have noticed the resilience to change that often occurs in quality improvement processes. Healthcare organizations are often burdened with power structures and hierarchies that affect the participants (Andersson, 2015; Alvesson and Cizinsky, 2018; Eriksson and Müllern, 2017; Hudelson et al., 2008), and the heritage from scientific management (Taylorism) on organizational development may act as a barrier to flexibility (Ekman and Simpson, 2020; Wise et al., 2017). Another potential obstacle to change is the unwillingness to accept knowledge from other fields besides their own profession (medicine) (Boström et al., 2020; Gadolin and Andersson, 2017). Handling complex challenges sometimes referred to as wicked problems, will demand competence and thinking from different fields of science (Batalden et al., 2016). However, traditional ways of solving problems and challenges within healthcare are mostly handled internally, very solution-oriented and the improvements are often incremental rather than radical (Vård-och omsorgsanalys, 2016).

Service design has been suggested as an approach that could be applicable in this context to involve and understand the users' needs, explore complex environments and contribute to improved services and innovations (Elg et al., 2012; Roberts et al., 2016). Malmberg et al. (2019) also show that service design could be a potential driver in complex transitions, specifically in the transformation towards person-centred care. Previously, design theory and practice have, to a lesser extent, been a part of the development strategies in the public sector, but in recent years, various healthcare organizations in Scandinavia have begun to build capacity around design in their organizations (Malmberg, 2017; Romm, 2021). What to consider, when building design capability within the public sector, and how theories around organizational learning need to be understood and applied according to that, have also been explored (Malmberg, 2017).

Nevertheless, there is, to our knowledge, less research that puts the spotlight on the healthcare leadership stories, on why design theories and practice in healthcare are needed, and on what knowledge gap they think it should fill. The purpose of the study is, therefore, to explore and describe the perspectives and reasoning of senior development leaders in healthcare organizations, when reflecting on design as theory and practice in relation to more traditional methods and tools for improving quality and support innovation.

Moving from certainty to uncertainty

Traditional methods and tools for improving quality

Since the end of the 20th century, healthcare has, in various ways, applied methods from the field of Quality Management (e.g. TQM, Lean, Six Sigma), to systematically address the requirements and needs of efficient and flow-optimized processes (Antony et al., 2019; Radnor et al., 2012). The knowledge has usually been transferred via business development roles (change agents) both externally and internally or through managers. The first theory development had its roots in the production industry, mainly in Japan (Deming, 2018; Juran, 2004). With that, methods and tools were focused on systems and on reducing variation and waste (Hellsten and Klefsjö, 2000). Since then, a shift has been made from the industrial era and its goods perspective to a society that has adapted to services and service logic (Barret et al., 2015). Therefore, according to van Kemenade and Hardjono (2019), there is a need to expand the theories in Quality Management and research and talk about the emergence paradigm. Quality is in this paradigm to be defined as dynamic and depending on continuous and broad dialogue which demands networking, systems theory and less positivism. Service research (Normann, 2001; Vargo and Lusch, 2004) believes that health and medical care should be regarded as a service, which means that it must involve collaboration to create value. According to that view, patients are seen as active co-creators and not passive recipients of healthcare (Elg et al., 2012; Vård-och omsorgsanalys, 2018b).

Design as a theory and practice for improving quality

Design as theory and practice in this article is connected to what can be found within design thinking in a healthcare context, which means to create empathy for the users, collaboration across borders/disciplines and prototyping where the experimental mindset is necessary (Boström, 2020; Brown, 2009; Roberts et al., 2016). A human-centred approach is essential and that implies having capacity and methods to investigate and understand people's experiences and interactions, but also their values and dreams (Meroni and Sangiorgi, 2011). According to Simon’s (1996) design is concerned with how things ought to be, in a contrast to natural science logic, which is concerned with how things are. Consequently, there is a movement from object to subject. It requires reflection and interpretation, which can initially be perceived as difficult, questioning and conflict-making (Alvesson and Cizinsky, 2018; Schön, 1991). Wetter-Edman (2014) stresses designers as professional interpreters of and through experience.

Shifting focus from processes to the user experience and needs, service design has been proposed as a way to change the innovation culture and practices within public organizations (Sangiorgi, 2014). When adapting design thinking and service design into healthcare organizations, this article acknowledges the model from Malmberg (2017) on building design capability in the public sector. Design capability is then understood as consistent of knowledge about design and ability to design. Organizations that have the ambition to practice design for development and innovation need to create awareness of design, identify design resources and enable structures for design practice (Malmberg, 2017).

Towards combining the two

The leadership importance for establishing prerequisites for quality improvements and innovation is well established in research (Bergman and Klefsjö, 2012; Kotter, 2012; Uhl-Bien, 2021). Batalden and Stoltz (1993) developed a framework to combine improvement knowledge with professional knowledge in order to gain continuous improvement (CI) in the daily work in the healthcare organization and stresses the importance of leaders creating conceptual space for the healthcare professionals. Furthermore, leadership need to create opportunities for new learning and nurturing curiosity about the work with improvements in the daily work. That could indicate what Markauskaite and Goodyear (2016, p. 162) talk about as epistemic fluency; “the capacity to understand, switch between and combine different kinds of knowledge and different ways of knowing about the world”. Uhl-Bien (2021) also highlights the importance of having leadership and followers that can respond to complexity by adapting instead of denying. To be successful in a world of uncertainty and ambiguity, conventional ways of thinking, acting and being need to be challenged by the leaders (Bushe and Marshak, 2016).

As the healthcare system now is going through transformational change triggered by the concepts of person-centred and integrated care (SALAR, 2022), it requires an understanding of how leadership can act in the unknown (Snowden, 2007) and also how it could adapt to complexity in the public sector (Stacey and Griffin, 2006). The leadership challenge could also be found in the gap between improving processes and understanding the users' need (Boström, 2020).

Method

This study had an exploratory design, with a qualitative inductive approach. Interviews were performed and analysed using content analysis as described by Graneheim and Lundman (2004) and Graneheim et al. (2017). The method is suitable when analysing individuals' experiences, reflections and attitudes (Patton, 2015).

Selection of participants and data collection

The Swedish health system comprises a large number of actors with joint responsibility in care delivery for approximately 10 million people. For example, there are around 100 hospitals, run mainly, by the 21 regional governments. From these regional governments, five development leaders (referred to hereafter as respondents) were recruited from five different locations in Sweden (Table 1). Four middle-sized regions and one metropolitan region. Inclusion criteria were that they (1) were a part of a national learning collaboration network around service design as a method and approach for developing healthcare services in a user-driven direction, (2) in their role as leaders (formal managers), had the mandate to influence the organization's development strategies and activities and (3) to some extent, had applied design theory and practice to improve quality in their organization. The number of participants was considered sufficient, given the criteria, the purpose of the study and the qualitative approach. This purposeful sampling (Patton, 2015) contributed to reflections between design and more traditional healthcare development methods and tools for improving quality and support innovation.

The participants were initially contacted by e-mail and asked if they were interested in being a part of the study and written consent was obtained prior to the interview.

Data were collected between autumn 2019 and autumn 2020. Two of the interviews took place at the leaders' place of work and three interviews (due to the COVID pandemic) were conducted using Skype. The interviews lasted 50–75 min and were digitally recorded and transcribed verbatim.

A semi-structured interview guide (Patton, 2015) was used to collect the data. The participants were asked to tell a story as detailed as possible about their occupational background in relation to their role as development and innovation leaders. Furthermore, to reflect on traditional quality improvement methods used in their organizations, and how they defined the traditional methods as well as design. The interview further included follow-up questions like why their organization became interested in design theories and practice; what experiences they have had so far; and to reflect on the future according to these different theories and practices in relation to the development of healthcare quality?

Data analysis

Initially, the transcripts from the interviews were read through several times by the first and second authors. This was a way to get an overall understanding of the material and, what Patton (2015, p. 432) refers to as, its “collage-like pieces”.

The text was then divided into meaning units that were condensed and coded, closely related to the respondent's experiences. Identified codes were collected on post-it notes in a digital workspace (Figure 1), interpreted for their differences and similarities and grouped into tentative categories. The first and second authors went through the coding process, discussed and compared their individual interpretations, adding and renaming categories and ensuring that the material was based on the collected data. The next step was to look for patterns in the categories by going back and forth. New insights came up when the authors moved between the manifest and more latent levels (Graneheim et al., 2017). Finally, the categories were abstracted to subthemes and themes ending up with a result showing the five leaders' perspectives and reasoning around design as theory and practice in healthcare.

Dealing with attitudes, assumptions, norms and values

The result (Figure 2) is presented through an overall theme: Dealing with attitudes, assumptions, norms and values. The overall theme is an aggregated interpretation of what the respondents are facing when introducing design theory and practice in their organizations, in relation to traditional development strategies, methods and tools. The theme is broken down into three subthemes; The world of healthcare development, Pushing traditional boundaries and Change in power dynamics. Those three subthemes are understood through seven different categories.

The world of healthcare development

The world of healthcare development according to the respondents provides a picture where the production of healthcare could be a challenging concept. Furthermore, that linear thinking in development sometimes hinders the contribution of other, necessary perspectives. Finally, there is also the question of how to measure development and change when risk-taking is threatening and solution orientation comes too early in the process.

The conceptual challenges

From the respondent's perspective, it is challenging to combine the concepts of service and production being in healthcare. One respondent says that it is just what healthcare is about, serving people in need of support from healthcare organizations. Collaboration and co-creation are strongly associated with service. However, some healthcare processes remind us of what is described in more industrial terms, and thereby more connected to production. For example, acute processes which consist of very structured and linear activities like X-ray and surgery.

Another challenge around the service concept is that the word service is also so connected with the term customer. That term makes a lot of public employees react negatively and especially so in healthcare.

There are two concepts that are more or less tabu in Swedish healthcare to use, one is customer and the other is service

Design and its processes are expressed to make it easier to understand the interplay between service and healthcare and therefore why a customer could be a term to use and how to make patients more involved and a part of healthcare development and increase service quality.

There was agreement among the respondents about the fact that healthcare as a system is changing. The movement is towards person-centred care and digitalization, as well as being an organization that can handle the need for individual solutions in complex situations. In describing the challenges of really understanding the needs of the patients there were doubts that the healthcare organization and its employees have what it takes in terms of mindset, skills and ability that are necessary to develop solutions for tomorrow. The respondents emphasized that in order to design services based on the individual's needs, one can not only ask a simple question to the patient; it is more complex than that. The real needs of the patient are in this context linked to a deeper understanding of the patient's everyday life rather than superficial issues.

Healthcare organizations are, according to the respondents, built on logics originating from industrial development and a change to a service logic perspective will take time. They believed that a radical shift is needed but will most likely happen in small steps. Developing a customer-oriented view was seen as necessary and an elaboration of the historically accepted expression “to have the patient in focus” to “having the patients' focus”. However, this movement has started, and it is, according to the respondents, both welcomed and yet challenging as the inside-out perspective is so rooted in the minds of both the organizations' members as well as in the system itself.

We have thought in terms of production because it is an inside out perspective. We have thought that, now we will produce as many hips as possible here. Because it's the objectification and so it's a hip. And some things are more industrial like production. It has also been somehow the mindset of healthcare strangely enough, because so much of healthcare is something completely different

Linear processes in a complex world

Emphasizing that designing services in healthcare is different than producing things in a factory questions the transaction model. Meaning that value is to be developed in co-creation and not as a traditional exchange process. The respondents were also aware of the fact that a lot of projects or assignments that are planned in healthcare have a linear approach. You must do A before B and the result from the projects are to be evaluated through numbers. One articulated example was the recurring question from top management on how production looks like when reporting on healthcare efficiency. One respondent reflected on the possibility that the methods, that are quite integrated into healthcare organizations today, from quality management, reinforce linear thinking. However, it was mentioned that most acute processes need a standardized way to work and, therefore, there is a need to use, for example, process mapping in order to reduce waste and shorten lead times. Nevertheless, it was also emphasized that there is a dimension which is lost and neglected, namely, the patient's personal experience, when going through a specific process, using this kind of tool.

The measurement expectations

Linear or not, the expectations from someone, sometimes defined as top management and sometimes the professionals, seem to challenge the service design approach of working with experiences and value-driven projects. Design projects, according to the respondents, challenge the demands of management to ensure efficient solutions before starting a project. They all underline the importance of measuring change initiatives, to understand if they are successful or not. However, projects that are more complex (as they tend to become), need different or other indicators for evaluation. Again, the quality and change management principles from Deming and Shewhart are mentioned, where more traditional methods sometimes lead to measuring what you can measure rather than what needs to be measured.

There is also an agreement to be found that design and design projects seem best suited to handle complexity, explore new ways of working or being in unknown and innovative processes. Problems could be found around the scalability on a system level when design projects are found successful. The respondents meant that there is a need to handle the expectations on measurement but also show the need for learning and using iterative design projects in addition to the more linear development approaches.

we are not trained to calculate system effects

One problem that was raised, in relation to expectation for measurable outcomes and solutions, was the fear of taking risks and that the organization usually develops things that are already known and that a possible solution somehow can be forecasted.

a problem in healthcare is that we often like a solution to solve the problem to 100 percent, despite the fact that it only worked at 20 percent before

Respondents with a healthcare professional background speculated that the healthcare system is made to be slow-moving in order to be evidence-based and that medical education also focuses on methods and approaches that seek repeatability and measurable accuracy. Consequently, they emphasized that there are problems when taking in perspectives that are different to the traditional way of doing things, and especially when a prediction of outcome is unclear.

There is a built-in scepticism towards everything that is new, especially if it differs a lot from the way you are used to working and I think that it’s what service design in healthcare does, that is the point of it

Pushing traditional boundaries

In the world of healthcare development, there are boundaries both to be pushed but also sometimes eliminated in relation to necessary change. The participants described barriers such as resistance towards new ways of thinking and doing, hierarchies and sometimes how different logics collide. Pushing boundaries or even moving beyond them may require learning a new “language” or at least using an interpreter.

Different approaches collide

The most explicit boundary mentioned is the boundary between the traditional way of working with systematic improvement and the more innovative processes. Innovation has been on the agenda for several years in healthcare but, according to the respondents, many regions still lack the necessary knowledge when it comes to the mindset, methods and tools used to innovate. Furthermore, they stressed that the average developer in the healthcare organization (a person set to work with improvement projects) is not equipped or trained with skills that are associated with, for example, creativity, visualization and collecting user experience. There is also some hesitancy among the respondents, as to whether management has the necessary knowledge of innovative methods and design. On the one hand, top management is said to have sufficient knowledge but that middle management is harder to convince. Innovation is, on the other hand, still a concept that is unfamiliar to most people in the organization. However, there is a consensus that if managers and professionals in healthcare are to be convinced, they must experience the methods themselves. One suggestion, if transformation is going to take place, is to place managers in situations where they really could experience the user's perspective through targeted interventions.

[…] but it was a very useful experience to suddenly meet, myself, this situation that when someone has thought to do something for the purpose of change with expressions that are in a completely different way than what we … I was used to

When the respondents reflected on new methods and tools challenges arise around its sustainability and efficacy, e.g. if the methods and/or tools will be out-dated and redundant in a couple of years, or if they really can contribute to higher quality. They described a potential clash between more rooted methods around Lean and Design, where their experiences with staff from different parts of the organization have shown that many have an approach that if you wait long enough, different methodological trends will blow over. However, resistance could also depend on various individual needs, e.g. a need for more predictable and well-structured development activities to be able to handle them in their complex working conditions. The respondents, therefore, suggested that a clear organizational and leadership strategy according to development was needed as a guide to lead the way.

[…] or some competence comes with its habit of drawing process charts and has to face a different approach, it collides, and then it is important to be there.

The traditional ways of working, as mentioned in the section on linear processes, are within limited boundaries, i.e. within your own clinic or department and where you as responsible manager or staff have a mandate and budget. The respondents considered these boundaries to inhibit possibilities for more radical changes where problems or solutions existed outside the area one has a mandate to govern and control over, e.g. another department, organization or in between. While service design and its focus on the user's perspective also apply in areas outside the doors of the department but is a consequence of the step before or an action that affects the step to come, a collision between mandates, the will to do good, and the financial frameworks often occurs.

[…] innovation […] where you really radically change how you work, and how you may change roles and responsibilities, then it’s usually not within your own business. You may put it in the space between different areas of responsibility and organizational silos, where everyone wants it but no one can take responsibility for it, because it is not in their regular responsibility. And then you do not really know how to relate to it […].

They, therefore, stressed that taking decisions around things that are a bit unknown will need courage from both politicians and management, as it may be easier to continue with traditional cost savings such as reducing staff, exemplified as “the cheese cutting method”, by one respondent.

Walking between borders

When working with innovations, one often positions the improvement work in the gap between or in a space where no one has real responsibility. Being there or moving between organizational silos or spaces requires people to be driven by curiosity, courage and an understanding of an organization's culture and way of working. This was all mentioned in different ways by the respondents. The respondents often returned to the hierarchical structure when they reflected on development and innovation and the problems which can occur when involving users in bringing in new ideas. They thought that solid structures are favourable when it comes to treatment and medical decisions. However, finding new ways of working or finding new solutions to old problems would instead benefit from a more flexible organization. One way to facilitate user involvement, proposed by the respondents, could be placing development and innovation activities away from the clinics. A consequence then could, however, be to close proximity to the place where the development occurs.

Another borderline question is about being able to bring development questions to the table at the top management level, in an environment that has its focus on healthcare production. The problem of bringing attention to service design issues is especially mentioned. But at the same time, the respondents highlight the fact that development in general is a topic that comes further down the agenda.

[…] was my experience, because there are so many things that are raised and that are important and if you are in the regional management environment, there are many balls in the air all the time and then this ball that you have added should create more … attention than all the other topics under discussion

They also emphasized that healthcare needs guidance from people with skills, capability and in some sense capacity of design. If the work requires a trained designer or if it is enough that people who are to carry out the design work have that perspective, there are different opinions. One respondent is certain that a person that is not trained as a designer could not visualize or produce material in a certain way. Another respondent says that people working with development don't need to be designers, but they need to have that mindset.

When you think like this, then it means this is in design language

Design comes with new terminology and new ways of working. This is mentioned in different ways not least that the language around this could be challenging. One of the respondents compared the situation with the way that specialist medical language sometimes creates barriers to understanding between administrators and professionals or between professionals and patients. Another comment emphasized the need for boundary roles taken by staff that have formal competence from both design and the medical profession (physicians). That builds trust and someone that can translate, especially in the contact with physicians, a group identified from all respondents as the one to convince when introducing new knowledge into healthcare.

Talk in different ways and meet all these who are proud advocates of their knowledge, and their process, and their rule. That´s what I think

The change in power dynamics

Developing new methods and engaging new perspectives or roles in the development of healthcare shake up the organization a bit. However, the respondents considered it necessary if healthcare organizations should be able to establish a welfare that can meet societal changes.

Expanding the roles of the participants

The professional's role in healthcare is shifting. Getting users involved is a real challenge, as this involves a change to both the professionals' but also the patients' traditional way of seeing each other. One respondent, as mentioned above, is certain that the welfare state must change direction if future health-related needs are to be handled. Another respondent, that has followed this healthcare organizational development for over 20 years, is sure that it is now that it is happening. Person-centred care, service logic, innovation and user involvement are key elements to achieving necessary change.

The balance in power relations between patients and professionals is changing but not necessarily in a negative way for healthcare professionals; one respondent that also has a professional background thinks the profession could come into its own. However, the strong, rather conservative, esprit of corps, within the medical profession, stressed by another respondent, can be problematic when it comes to letting other perspectives in.

Healthcare is a rather hierarchical and conservative culture.

When it comes to service design and design thinking, the comments highlighted the importance of starting the process with the patients' need and involving them in the development of healthcare. A problem mentioned is the fractionalized system, where patients are assumed to have a passive role in the processes. According to one respondent, this is most apparent when entering the system without a professional healthcare background.

[…] it was when I got the insight and saw how it actually is quite so … how to put it, divided. That you often take a rather passive role, if you are a patient.

The respondents also meant that healthcare needs to expand its relations to the surrounding businesses that could be partners or deliver services and products that healthcare could use to meet present and future demands. It was also mentioned that the actual care of patients is not the only aspect of the process around healthcare. Fear of using tax money for other things than traditionally healthcare-related processes, in a wrong way, and taking risks in a risk-averse culture are mentioned as obstacles to external relations. However, this would not really be a problem if handled properly.

Oh, there is a lot of sponsorship of care, and we must not do that. And that's definitely not what it's about! It's maybe about us getting together in a project, everything is transparent, you rig agreements, you put it in the diary for anyone to request, there are nothing strange about that.

Balancing hard and soft methodologies

Looking back, traditional tools from quality management have been prioritized (statistics, variation analysis). The respondents stressed that the deeply rooted culture around natural sciences often means that politicians and care management request quantitative methods rather than qualitative ones when asking for follow-ups and evaluations when planning for development. However, they emphasized the importance of ensuring quality through process management and documentation but also commented that this can limit creativity.

Because if we continue in the same way as ever, we’ll simply get the same results and healthcare will just go on improving existing processes.

They argued that qualitative methods (e.g. interviews, focus groups, workshops, observations) could bring in new perspectives that have been missed and create opportunities to see how to do things in a new way. Facing a more complex reality, and digital transformation imply that new methods and tools must be used along with old ones, and they believe that design offers one new perspective.

If we should make a transformation and transformation is to really change and find new value-creating processes, we must complement … not replace and discard the old, but supplement with new tools in the toolbox that fit when we have to make completely new solutions

The design perspective aims, according to the participants, to make people act in a specific way. The sensorial feeling becomes more and more important to understand and use when developing healthcare. However, the methods need to be presented in a manner that makes things understandable and trustworthy.

I mean, facts lead to conclusions but emotions lead to action

Discussion

In 2009, an article was published (Nordgren, 2009), stressing the absence of a support system around value creation processes for the customer, and more than a decade later it seems to be still highly relevant according to these leadership stories and their context. The perspectives and reasoning revealed in this study can be interpreted as an ambition to move from the goods-dominant logic approach where the healthcare system produces healthcare to the service-dominant logic where healthcare co-produces services that generate value according to the theories that Vargo and Lusch (2004) describes. New methods and models based on collaboration and relationships must be developed to handle complexity which, according to Cottam (2020), will lead to an updated welfare state. Eriksson et al. (2020) stress boundary-spanner roles with inter-organizational missions and supporting structures that support both vertically and horizontally. Those roles will need to feel support and a sense of trust to work in sometimes lonely space. Trust increases the space for action (Tillitsdelegationen, 2019), and trust is established through relationships. This is strongly aligned with the relationship theories on how to achieve, among others, higher quality and efficiency in an organization (Hoffer-Gitell and Ali, 2021). However, this study indicates a paradox of whether this is a culture to build with the existing organizational resources, or if you must recruit the right people.

Information today is in everybody's hands literally speaking. With access to the digital world, patients have gained increased expertise about their own situation and diagnosis (Snow et al., 2013; World Economic Forum, 2019). The complexity of human nature, its behaviour and its innermost essence, forces healthcare to also take this into account when developing care. This study describes the challenges, where there is a need for methods and tools, but perhaps also approaches that could support this paradigm shift.

The obstacles experienced in the healthcare sector which the result highlights, in the form of hierarchy and unwillingness to embrace knowledge, are a challenge and are confirmed by previous studies (Andersson, 2015; Alvesson and Cizinsky, 2018; Eriksson and Müllern, 2017; Hudelson et al., 2008). The methods from design can be perceived as foreign in the natural sciences context as the healthcare system is characterized. When knowledge is viewed from a technical-instrumental perspective, the purpose is to incorporate information and structure into it, preferably quantitatively, and then develop knowledge and methods of objective processes, following the principles of finding the relationship between cause and effect (Alvesson and Cizinsky, 2018). This is recognized in health and medical care's natural science tradition and professional knowledge (Alvesson and Sveningsson, 2019; Batalden and Stoltz, 1993). The result of this study strengthens the picture of a healthcare system which needs to create acceptance of knowledge for development methods from other fields. Given the technical-instrumental knowledge perspective (Alvesson and Cizinsky, 2018), a design could rather be compared with the interpretive-understanding knowledge perspective. This is described as a holistic approach that is based on a deeper understanding of phenomena that arise. It requires reflection and interpretation, which can initially be perceived as difficult, questioning and conflict-making (Alvesson and Cizinsky, 2018; Schön, 1991). The transformation towards more person-centred and integrated care [Nära Vård] positions the need to establish a holistic approach to people but also to the entire health system (SALAR, 2022). This is consistent with Von Heimberg and Ness (2021) reasoning on creating public value through cross-boundary and multi-level collaboration to reach relational welfare. The respondents in this study call for resources (capabilities, capacity, methods and tools) that could support this movement.

That the management's role and leadership is central to transformation, improvement work and learning in organizations is well-documented (Batalden and Stoltz, 1993; Bergman and Klefsjö, 2012; Granberg and Ohlsson, 2014). Creating the conditions for, and maintaining, structures/cultures that lead to major changes requires curious and maybe courageous leadership; otherwise, it will be difficult to convey and maintain important parts such as involvement and participation during the journey. This study's respondents have shown the possibility of taking responsibility for this in their roles, but also see problems when they themselves do not lead departments that manage the core processes (healthcare services). Being in the healthcare management environment, they feel a need to demonstrate results and a clear why and how some methods may be preferable to others and that is challenging. Going back to the model from Malmberg (2017), on building design capability, the result indicates increasing awareness of what design can contribute to the development and innovation of healthcare. However, there are less signs in this study of a strategic discussion on how to identify and obtain design resources in their organizations and what necessary knowledge leadership should obtain and retain.

Conclusion

The overall conclusion from this study is that these leaders experience a constant balancing act around attitudes, assumptions, norms and values in relation to pushing traditional boundaries and questioning the power structures when it comes to the professional actors, management and what theories and practices to use to increase healthcare quality and support innovation (Figure 3).

The result emphasizes the need for a spectrum of competence, skills and capability in how to manage a changing healthcare world. Understanding history is important to be able to navigate in this world. However, going into a new landscape also requires leadership and organizations that are open to new and different perspectives. The result indicates that organizations need methods and tools that can contribute to meeting the requirements that are being made for healthcare services both now and in the future. Traditional methods that focus on efficiency and flow are applicable to processes that are well-defined and where there is a need for improvements rather than finding completely new solutions. Knowledge from design theory and practice has been able to respond to the expectations they have had on it so far to be a method for the latter. Furthermore, the result shows that the knowledge that comes from design can be difficult to convey verbally and must be experienced to be understood. Today, the organizations that have been investigated in this study seem to lack resources when it comes to knowledge and capability, to be able to meet the increased demand for design and efforts to educate are necessary. Nevertheless, specialist expertise must also be ensured. One major challenge seems to be the transformation from the way to see healthcare as a product into a more service logic mindset. Mostly, this challenge concerns individualization and whether patients are customers or not.

According to the result, these organizations also need to push traditional boundaries as mentioned above but the result could also be interpreted as a need for these leaders to highlight the limitations of linear thinking, quantitative measurement and treating healthcare professionals as the only experts in the healthcare ecosystem. Doing so will also mean that they need to open doors for new ways of thinking and doing. According to themselves, they will need to both set preconditions for training and education as well as hiring professionals, in this case, designers, to build the necessary competence and skills. Doing that they seem aware of the possible change in the power structures, mostly from the change in roles for patients and physicians but also that the hierarchical structure will be affected. The results establish that these solid power structures are less favourable if this system should be able to create conditions for new perspectives and/or others that, today, have difficulties to contribute or co-operate with the traditional healthcare organization and its professionals.

This study also indicates that healthcare culture has difficulties to embrace knowledge from other fields such as design or the user's experiences which could be challenging. When it comes to dealing with attitudes, norms and values when increasing healthcare quality and support innovation, the results stress that there is potential for leaders and their organizations to handle complex challenges when combining theory and practice from design with more traditional and well-known methods and tools. The result also underlines the need for curiosity and courage to be able to balance a seesaw with a wheel in the middle that is constantly moving (Figure 3).

Implications for practice

The narratives from the leader's experience of design theory and practice for improving healthcare quality could help us create readiness and knowledge about how we prevent and/or facilitate planning and implementing design projects in a healthcare context. But also, that design plays an important role in organizations' ability to both develop and radically meet the challenges of the future.

Being in a leadership position, one may consider how to inform and communicate to the top management and political level, how different development approaches, models and tools are complementary and context-dependent. Along with that, the organization must be able to organize for the capability of both CIs and radical change (innovation). Going back to the research done by Malmberg (2017), healthcare management needs to handle the questions around awareness, resources and structure in relation to design and CI. Developing capability can be understood in line with Malmberg:

[…] to develop design capability that is sustained in the organization and it is not tied to and/or dependent on individuals in the organization, it is not enough to only acquire design through explanatory learning. To develop design capability also entails structures that enable the use of design competence and practice (Malmberg, 2017, p. 233)

In sum, the mayor implications for practice in order to combine and balance design and traditional development strategies in healthcare are.

1. Challenge assumptions, norms and values by making them visible

2. Make space for interdisciplinary teams

3. Take care of boundary spanner roles

4. Understand and apply practices, methods and tools for your context. It is not one-size-fits-all

5. Bring the question to the top management and political level

6. Build complementary organizational capabilities in terms of knowledge, resources and structure for both design and the traditional development strategies and practices of CI

7. If you want change – do something different

Implications for research and future research

Future research should benefit from co-creation and combination with other knowledge fields in order to meet the demands of practice. Taking a more action-oriented approach, the research could also respond more quickly and contribute with understanding back to organizations where research is conducted. More specifically, a mixed-method approach could be used to combine quantitative and qualitative data about leaders’ (formal and/or informal) experiences in a healthcare context. Data could then be captured about challenges when balancing questions around knowledge for improving and innovation on a daily basis. By setting certain measurable actions (use of knowledge, methods, tools, resources, etc.) and combining that with the stories and reflections of selected individuals using a longitudinal method, a broader picture could extend and complement these research findings.

Methodological considerations

Qualitative research could create concern as to how transferrable the result is to other settings. Our purpose has never been to generalize, but to create trustworthiness (Lincoln and Guba, 1985; Patton, 2015). Our intention was to get a deeper understanding of how the design theory and practice are experienced by the leaders who have begun to incorporate design into their organizations. This is also the leader's perspective, and the professionals and other groups may have described it differently.

Figures

Figure 1

The data analysis process in a digital workspace

Figure 2

The result as one overall theme, three subthemes and seven categories

Figure 3

The seesaw balancing act, as an interpretation of what leaders and healthcare organizations experiences, when it comes to combining design and traditional development strategies to increase healthcare quality and support innovation

Table 1

The respondent's field of operation

Respondent	Organization/Population	Department	Role
Respondent 1	Regional Healthcare >1,000,000	Regional Innovation	Head of Innovation
Respondent 2	Regional Healthcare <500,000	Regional Research and Development	Director of Research, Education and Innovation
Respondent 3	Regional Healthcare <500,000	Regional Department of Development	Development Director
Respondent 4	Regional Healthcare <500,000	Regional Department of Development	Development Director
Respondent 5	Regional Healthcare <500,000	Regional Department of Development	Development Director

Source(s): Table by authors