Human-centered design is about understanding human needs and how design can respond to these needs. With its systemic humane approach and creativity, human-centered design can play an essential role in dealing with today’s care challenges. ‘Design’ refers to both the process of designing and the outcome of that process, which includes physical products, services, procedures, strategies and policies. In this article, we address the three key characteristics of human-centered design, focusing on its implementation in health care: (1) developing an understanding of people and their needs; (2) engaging stakeholders from early on and throughout the design process; (3) adopting a systems approach by systematically addressing interactions between the micro-, meso- and macro-levels of sociotechnical care systems, and the transition from individual interests to collective interests.
Keywords: user-centered design, human factors, user needs, stakeholder involvement, sociotechnical systems approach, patient journey
In recent years, new forms of patient care have been introduced to guarantee safe and high-quality care. Many of these approaches focus on organizational optimization and the needs and values of the stakeholders [1]. Examples include organizing care in dynamic multidisciplinary teams of medical professionals to coordinate mutual communication and diagnosis (e.g. networked care [2]), steering treatment on outcomes that matter to patients (e.g. value-based health care [3]) and active patient participation throughout their care path (e.g. shared decision-making [4]). Designing and implementing these new forms of care involve major organizational change and demand a holistic systemic approach towards health care. It also requires dedicated, well-designed interventions—i.e. products, services, procedures—to be used by patients, care givers and medical professionals to facilitate and implement these envisioned forms of care.
Human-centered design (HCD), with its systemic humane approach and creativity towards change, can play an essential role in dealing with today’s complex care challenges [1, 5, 6]. The field of HCD revolves around discovering human needs, so as to design products or services that meet these needs. The resulting design is understandable and usable, it accomplishes the desired tasks and the experience of use is meaningful and pleasurable [7, 8]. Characteristic of HCD is its holistic, systems approach towards human needs, ensuring that solutions fit the dynamics of the (complex) sociotechnical system the user is part of. Note that ‘design’ is a broadly defined term used for both the process of designing and the outcome of that process. Moreover, design is no longer used as a process to create physical products only, but increasingly as a process that leads to the creation of any type of intervention that changes existing situations into preferred ones. This includes services, procedures, strategies and policies [7, 9]. A large variety of methods and principles exists supporting the HCD process, each with its own specific purpose within the design context or phase of the design process [7, 10]. Examples of HCD methods range from shadowing and contextual inquiry to investigate human needs to co-creation and usability testing to develop solutions. The HCD discipline is closely related to that of Human Factors (HF) and the terms are often used interchangeably [9, 11]. Furthermore, there are many closely related design (research) disciplines using HCD principles and methods without explicitly being called HCD, such as user-centered design, design thinking [12], service design [13], experience-based design [14] and participatory systems approach toward design [15]. In HCD, as in all design disciplines using HCD principles, designers rely heavily on the tools, methods and insights from the HF discipline, as illustrated by the definition of HCD by the International Standards Organization (ISO): ‘Human-Centered Design is an approach to interactive systems development that aims to make systems usable and useful by focusing on the users, their needs and requirements, and by applying human factors/ergonomics, usability knowledge, and techniques. This approach enhances effectiveness and efficiency, improves human well-being, user satisfaction, accessibility and sustainability, and counteracts possible adverse effects of use on human health, safety and performance’ [16]. The evolution of HCD and HF started after the Second World War; they were viewed as ways to increase the efficiency of industrial production by ‘fitting the task to the worker’. Since then, the focus has elaborated from the physical and cognitive characteristics of users towards their organizational, social and emotional needs and pleasurable experiences [7, 9].
HCD is increasingly recognized as being a valuable contributor when addressing today’s complex healthcare challenges (e.g. [5, 6].). In their editorial ‘Redesigning healthcare to fit with people’ in the British Medical Journal, Erwin and Krishnan [5] aptly describe HCD’s added value: ‘The key is to shift our focus from helping people to fit our care delivery system, to one where we design our care delivery system to fit people where they live, work, learn, play, and receive healthcare.’ Many healthcare organizations realize that becoming more human-centered is key to dealing with today’s care challenges. However, although HCD is increasingly being adopted in healthcare practice, little has been published on what an HCD approach entails when applied to healthcare organizations. In this article, we address the three key characteristics of HCD and how they relate to the context of health care: understanding people, early and continuous stakeholder engagement and a systems approach.
The emphasis of HCD is on human needs and how design can respond to these needs. Understanding people, how they think, how they behave and how they are influenced by their environment (i.e. their sociotechnical system) is therefore conditional before the actual development of an intervention can start. Or, as the well-known US-based design agency IDEO coined it in their HCD Toolkit: ‘Human-centered design begins by examining the needs and behaviors of the people we want to affect with our solutions’ [17].
A widely used visualization of the HCD process is the Double Diamond Model (see Figure 1), developed in 2004 by the British Design Council [18] and which has been applied and adapted by many designers since. The double-phased model underlines the key principle of HCD: first finding the right problem (‘designing the right thing’) and then fulfilling human needs by design (‘designing things right’) [8]. The first diamond is often referred to as the problem space, the second as the solution space; terms stemming from the design thinking practice, a practice closely related to HCD. The diamond structure emphasizes the divergent and convergent stages of the design process, referring to the different modes of thinking that designers use; a process of exploring an issue more widely or deeply (divergent thinking) and then taking focused action (convergent thinking). The HCD designer starts by questioning the problem given to them: they expand the scope of the problem, diverging to examine all the fundamental issues that underlie it. Then, they converge on a problem statement. The knowledge of users and their context is then built on, to develop suitable solutions; the second diamond combines divergent and convergent thinking to determine an appropriate solution. First many ideas are created and evaluated, before refining and narrowing these down to the best solution [8, 18].
The Double Diamond Model (adapted from [18]), visualizing of the human-centered design process. The first diamond represents the process of divergence–convergence to determine the actual problem. The second diamond combines divergent and convergent thinking to determine an appropriate solution.
Following the Double Diamond Model, the HCD design process is divided into four main activities: Discover, Define, Develop and Deliver [18]. Discover is about understanding, rather than simply assuming, what the problem is. It involves studying the people affected by the issues. The insights gathered from the Discover phase help to define the actual problem. Develop, the first activity in the second diamond addressing the solution space, encourages designers to explore different answers to the defined problem, seeking inspiration from elsewhere and co-designing with a range of stakeholders. Deliver involves small-scale user testing of different solutions, rejecting those that do not work and improving those that do. The four activities—discover, define, develop deliver—are iterated; they are repeated over and over, with each cycle yielding more insights and getting closer to the desired solution [8, 18].
A common occurrence is that the initial brief given to a designer already describes the problem to be solved. The human-centered designer will always start by going back to investigating the problem space to verify whether the given problem is the actual problem. An example of this in healthcare design is given by Mullaney et al. [19] who describe how their design team was asked by a cancer center to reduce patient anxiety during radiotherapy treatment. The center used to focus on reducing patient anxiety by offering coping strategies taken from nursing theories on coping and disease management. Mullaney et al. started their HCD process by first investigating the situational triggers of patient anxiety in cancer treatment, and this led to a broader understanding of the problem area and its solution space. A key trigger turned out to be the fixation technology during radiotherapy treatment; “the fixation device confines the patient to a passive, disempowered role within its interactions due to it being embedded with the socially scripted ‘sick role”’ [19]. Starting from this holistic view on patient anxiety, they reframed the problem and started their idea development phase. Another example is Simons’ design project [20], who was asked to improve the patient experience of children admitted to a pediatric acute medical unit (P-AMU). Simons started investigating the problem space by observing and interviewing children, parents and medical staff and mapped their journey from being admitted (unexpectedly) to the emergency department (ED) to being transferred to the P-AMU and being discharged (to home or a regular nursing department). The patient journey (PJ) clearly showed more fluctuation in patient’s emotions and more innovation opportunities at the ED in comparison to the P-AMU. She concluded that improving the patient experience at the P-AMU started with improving the patient experience at the ED and reframed the initial design brief. Both examples emphasize the overriding principle of HCD: make sure you solve the right problem by first acquiring a deep understanding of the people you design for.
Table 1 provides an overview of the HCD tools and methods as discussed in the examples in this article. Note that this overview is far from complete. It does provide an overview though of the most common HCD tools and techniques used to collect data throughout the different design phases.