1. Touchpoint 7-158
as impersonal, standardised, and routine.
The choices we make, every minute, every
day, for every patient are ones that we
know to be right but their logic or value is
not perceivable to patients.
As designers of services, we
must understand the system that the
service supports and the behaviours it
perpetuates. Often we must question that
system as much as we reflect it. It is not
sufficient to build a service that considers
the end user experience but more one
that exposes the system and makes it
tangible, understood and accessible.
Service design when done well focuses
on giving the user power, control and
influence. It offers options and choice by
demystifying the systems and inviting
the user to feel invested and engaged in
its success. We have found that once a
user understands the hidden drivers of
healthcare services that are significantly
more likely to act in concert with them.
In healthcare, the potential for an
empowered and informed user to catapult
Designing for Consequence
How to plan for the enduring effect of design
in complex systems
Though currently considered very different design arenas,
services are frequently the window into systems. When a
customer engages with a service, they are, in fact, being drawn
into the top layer of a system. Like a giant iceberg, the service is
what has been made visible, what can be known.
It is just a tiny fraction of a much more
chaotic system hidden beneath the
surface. This is never truer than when
someone encounters healthcare services.
They collide with a system so obscure,
so daunting in its complexity that the
experience itself can be disorienting at
best but more typically, terrifying.
How they navigate the system is
through the service cues we design. We
allow them just a select glimpse of the
whole, with the complexity hidden so as
to not confuse the user. We design the
access and influence points to direct and
focus their involvement and to manage
their inputs only where the system can
tolerate them. In healthcare, this is done
because the system has evolved to be
simply too confusing to explain, and with
this confusion comes increased volatility.
Existing as two parallel universes, the
needs of the system often contradict
the needs of the user. In the healthcare
system, we optimise to mitigate risk, to
keep people safe. This can be experienced
Lorna Ross, a graduate of The
Royal College of Art (London,
England), has 24 years'
experience in design, design
research and innovation, with
the past twelve years focused
on health and healthcare.
She is a strategic leader
in directing the discovery
and implementation of
transformative, user-centric
care models at the Mayo
Clinic Center for Innovation.

2. Touchpoint 7-1 59
sdgc 2014
break for a reason, probably because they were not
adding value and so the system is trying to rewrite
the story without them in it. Take, for example,
the patient who keeps turning up in the emergency
department despite numerous directions to seek care
services through their primary care clinic. Though
considered a deviant in the eyes of the clinician, they
are in fact a super-user of sorts. They have determined
that the just-in-time services offered in an emergency
department are significantly more compatible with
their family’s unpredictable healthcare needs than the
limited fixed hours of a clinic. When users forge new
pathways in the system it is typically because they have
figured out the most direct route to value for them.
the industry to new paradigms is so potent that the
opportunity for service design is less a one of successful
translation and more of radical adaptation. The design of
compelling, meaningful and effective healthcare lie less
in clever interfaces and tools to the existing system and
more in allowing the user to determine through their
actions where real value lies.
Design, like science, is a tool for understanding,
as well as for acting. It offers us a process by which
complex and confusing issues can be examined and
considered from intersecting perspectives. Good
design rarely focuses on fixing things, but rather more
on transforming things. The subtle, but important,
difference is that, in complex systems, most things
Em nihiti nos sin reius. Alist estiam, ut labore natem auta dolent. Agnimus

3. Touchpoint 7-160
most disturbing of all, at increased risk of error and burn-
out.
I have recently been struck by how effectively
service designers create maps (often giga-maps) and
models of the system they are hoping to innovate, but
when they move towards proposing solutions their
thinking becomes less dynamic. It may be that the
thinking and seeing tools we have developed are so
comprehensive that they lay bare possibilities that
our ‘doing’ tools do not know how to manage. To use a
medical analogy, our treatment tools lack the precision
and sophistication of our diagnostic tools.
I would pose the possibility that we should think
about designing less for mitigating risk or managing
uncertainty and more for having an enduring effect. We
need to utilise our advanced skills in seeing cause and
effect, not only when we study systems, but also when we
attempt to transform them.
A designer’s systems view is less the discrete parts
and more the dynamic relationships between them.
When considering any action, you can estimate both the
If we want our service systems to succeed and scale
we need to design for internal fragility, competition and
obsolescence.
It has been an enduring experience of mine,
consistent across the five innovation labs I have worked
at, that the paralysing anxiety of managing risk while
innovating complex systems, biases groups strongly
to favour additive rather than subtractive concepts.
Universally, there is greater tolerance for innovations
that promote additional elements than those that
challenge the value of existing ones. Complex systems
grow increasingly complex simply because of the risk
in destroying things. These systems tolerate huge
redundancy and inefficiency to maintain the status quo.
No one knows this more than the nursing staff in
our hospitals, burdened by the increasing demand for cus-
tomised standardisation, transparency, customer service
to compliment the more standard delivery of exceptional
service outcomes, they find themselves crippled by the
cumulative effect of trickle down service innovation and,

4. Touchpoint 7-1 61
sdgc 2014
benign experiment had a snowball effect that rippled
through the entire care model. So much so that, when
these mothers delivered, they were loath to engage with
paediatric services as they, too, practiced a similarly
institutionalised and professionalized infant care model.
Having had the experience of control and autonomy,
the patients were significantly more dissatisfied with
the absence of this and became powerful advocates for
reform. The impact and effect of this experiment was
to activate the patient as change agent and allow for the
implications of the concept to ripple out in a cascading
series of triggers.
I would challenge the service design community to
become less enamoured with our ‘seeing’ tools and work
quickly to advance our expertise in the ‘doing’ or impact
tools. In the future, as service and systems design become
more complex, we will be asked to tackle greater and
greater problems. We must understand how to design for
effect, for enduring impact,for... consequence.
desired effect and also the indirect effects equally. Often,
to effectively adjust dynamic systems, it is better to
design for consequence, for a cascading impact, that for
local or direct effect.
An example of this from our work at Mayo is an
experiment that we ran with expectant mothers, where
we gave them access to foetal heart rate monitors 24/7.
This was framed to the OBGYN department as a simple
efficiency in reducing the demand for reassurance,
particularly during the final trimester. What it did, in
fact, was to fundamentally challenge the existing care
model where the tools resided with the institution
and access to them constitutes the service. Here, the
experiment of transferring the location of the tool in the
system away from the clinician and to the patient was
effective, not only in solving the immediate problem
(demand for reassurance) but it more importantly had the
consequence of triggering a fierce appetite in the patient
population for more control. The overly medicalised and
professionalised aspects of pre-natal care in low-risk
pregnancy were called into question and a seemingly
Em nihiti nos sin reius. Alist estiam, ut la-
bore natem auta dolent. Agnimusa volorias
ipsapic temquiae nonesequissi doluptate
non cuscim ium quae maio. Itatetus mil-
lorepel id mi, qui simint quis reicim fugia ab
inverunt reiciusaped quias num inus pedi
blam voloren dendis sae volut ad quibu