Compassion in Healthcare at Torbay Hospital

Last month Mum mentioned she’d seen a talk advertised in the library, it was being held at our local hospital and was being given by Sarah Tobin. It was on a Monday evening, a day I worked at home, Mum was curious and thought it might be of interest to me from a work perspective. So we agreed we’d go and I did a quick google to find some info and came across this. The event was the first attempt at a Health Science Cafe event being held at the hospital and most importantly they’d be free parking, a small but important manner. If you were to play a word association game with anyone who has had anything more than casual use of the health service I’m confident it wouldn’t take long before they mentioned parking – finding a space only being half the battle. Anyhow, I digress, this was an early evening event with free parking and Sarah Tobin, what was not to like.

Who is this Sarah I hear you ask? Sarah was one of the many professionals who provided support for my Dad, and all of his family, when he was first diagnosed and through his treatment for bile duct cancer. Specialist nurses are worth their wait in gold, they have intricate knowledge of what you are facing, have always made themselves readily available, always *always* return your phonecall if you have to make one, have the ability to unlock doors and generally give a sense of confidence in a quite daunting experience. I guess you could think of them as nursing sherpas who guide you through it all….we were lucky to have the support of several different ones and they all helped enormously.

Last Monday we arrived at Torbay Hospital, parked up and I checked in on Foursquare and was delighted to see I’d not been to the hospital in nearly six months. Dad died last November and until then I think I had visited at least every four months and in the latter stages of his life far more frequently, with a large number of visits as an emergency admission. The last time I’d been at the hospital was to drop Mum up to deliver thank you tins of chocolates to the staff who had cared for Dad. I still wasn’t really sure what to expect but off we went.

We were greeted by Helen, the Trust librarian who came up with the idea of the Health Science Cafe at Torbay. She had mentioned in the press release linked above that she felt it was important for people to have the chance to visit the hospital site for occasions other than just to meet medical need. One of my take home thoughts from the evening was how good it had been for me to return to the hospital that has played such a significant role in our lives over the last five years, with a positive reason. To drive up without the nagging doubts, the butterflies, the anxiety, the stress. To be honest it felt a little odd, after we’d parked up I had to remind myself that there was nothing to worry about!

The talk was very informal, there were about ten of us there although I think most people were previously associated with the hospital in some formal way. Sarah introduced herself, she now works 0.5 as a specialist nurse and 0.5 in teaching and education. She told us a little of her own personal experience, and indeed what fuels her interest in this area, and about her masters that focused on whether you can teach compassion and her current PhD studies in the same area.

She went on to talk about a number of key approaches adopted within SDHT (South Devon Healthcare Trust) to support work on compassion. These included:

Patient storytelling – this was introduced as a benefit to patients, where they are given the opportunity to share their experience. Their experience is tape recorded, transcribed and then shared with teams in a facilitated discussion designed to identify future improvements.

Observations in care – after a day long training session people are given 2o minutes to observe a ward/healthcare experience. Observers work in pairs, they note down what they see, hear and smell, purely as objective observations with no reasoning or judgement attached to them. They compare and contrast their notes after 20 mins and feed back to the staff members they have observed.

Schwartz rounds – this approach developed in the US at The Schwartz Centre and piloted in the UK by the Kings Fund provide a monthly, one-hour session for hospital staff to discuss difficult emotional and social issues arising from patient care.

Other approaches discussed included the development of a Leadership Programme for nurse leaders and ward managers, the introduction of the Friends and Family test, and Jeremy Hunt’s new requirement that nurses work for a year as healthcare assistants before training. The discussion was wider than just the steps taken to increase compassion, we also discussed the issue of complaints (90% focus on communication in some way), the changing shape of training over the years to include a greater focus on communication skills, the balance of positive to negative feedback (3:1), pride in nursing, how to gather feedback to get a hospital wide picture, the number of patients in hospital and their reasons for being there (80% of the surgery carried out at Torbay is now done as day surgery – this leads to changing methods of patient care, changing demographic of inpatients and so on).

Media Impact Mention was also made of the media and the negative expectations that many people have of hospital care, before experiencing it for themselves or those they care for. Initial analysis of the Friends and Family test feedback at Torbay commonly reports ‘it was loads better than I was expecting’. The local paper had been invited to advertise the Health Science Cafe and run a story on it, they had declined the opportunity. I can’t help but feel bad news sells more newspapers than good! Maybe they’ll get behind the later events, perhaps even send a reporter along to share with a wider audience.

Our discussion of the impact of the media also extended as far as two fly on the wall documentaries currently showing on TV, 24 Hours in A&E filmed at King’s College Hospital now in it’s third series, and Keeping Britain Alive: the NHS in a day filmed across the NHS on Thursday 18 October. I have a real interest in these documentaries, part morbid fascination with something new, part as an example of human behaviour and within that the compassion captured, part also as a reminder of how lucky we are to have a national health service.

While I imagine only certain people are interested in these programmes (best viewing figures for an episode of 24hours in A&E just top 3million people, Eastenders and Coronation Street routinely get double or three times that), that is still a large pool of people who do appear interested in this user generated content. One Born Every Minute, another Channel 4 documentary series now in it’s fourth series is set in an NHS Maternity Ward and clocks viewing figures of almost 5million; it’s not clear what exactly it is that people are interested in but I’d hazard a guess that it is part real-life stories that could as easily feature us and our family members as players that attracts them. Thinking about the three approaches Sarah had discussed one of the common features of them is reflected in this documentary approach, they all give a real-life focus and focus on the experience (of patients or staff) and allow for reflection on that experience as a prompt to identifying learning points, or building resilience, and also in humanising people.

This blog post was designed to share the experience a little more widely, partly because I was left with quite a few ideas and questions I’d like to think of further, so your own thoughts and experiences are very welcome. A lot of my thoughts were about how it’s possible to create a common team/organisation wide focus that focuses on an individual’s experience of compassion; how you define, or develop a shared definition of compassion; how you keep learning and reflections alive and tangible; whether there is enough focus on positive feedback as well as negative; how important and value laden compassion is – perspective being key; whether certain environmental circumstances are likely to reduce, or increase, compassion; and whether greater focus on staff members’s as individual’s could create behaviours among patients that increase their own chance of being treated compassionately (and vice versa)! What do you think?

A game of odds #cancer

A week ago I wrote a post explaining Dad’s latest situation with #cholangiocarcinoma Don’t give up the ship, fight her till she sinks. At the time we’d just seen his oncologist and heard the news that Dad’s one remaining option was to have chemotherapy in an attempt to stem the tumour in his stomach bleeding, which in turn is causing him to become severely anaemic and requiring regular blood transfusions.

On Monday Dad went to the unit where he receives the chemotherapy to have his prep session and bloods taken. Less than a week since his last transfusion and he’s anaemic again and his haemoglobin level was down to 7. The fantastic staff did all that they could and managed to fit him in on Tuesday for another blood transfusion, in order for him to start chemo today as they’d originally planned. All of this organised at the drop of a hat, with Dad’s specialist nurse doing what he seemingly does best, twisting arms and calling in favours. So today was his second day at the unit, ten hours at a time, so far so good. The chemo is very risky for Dad, but its a game of odds and the balance of probabilities suggests that doing nothing is even riskier.

Possible side effects include all the usual things (anaemia, hair loss, constipation, wind, loss of feeling, impaired immune system), a major bleed (not surprising given the amount of blood he is losing anyway) and neutropenic sepsis.

Dad has had sepsis on a couple of occasions, including the last time he was on chemo, they’ve warned us that the most dangerous time will be this weekend. Anyone who has ever been taken ill on a weekend, never mind a Bank Holiday, never mind Easter…will know that you don’t want to end up in A&E then. That said, I’m really impressed with the fact that they have raised the issue and reassured Mum that we have to be explicit that we need attention, and it’s also good to know that the hospice palliative care team are aware too. Unless you’ve had to do it I don’t think you can necessarily appreciate how hard it is to request attention once you’ve been admitted into hospital, especially in a busy A&E Department where you’re surrounded by other poorly people. This leaflet, and it’s explicit time bound permission statement to go back and insist on action, is really powerful stuff. Very impressive. This flimsy piece of A4 paper could make the difference on whether someone like Dad survives, I know that with this piece of paper in her hand my Mum would go and ask for further attention, without it there’s a slim but outside chance she might speak up but evidence so far suggests she’d rather not make a fuss/appear ungrateful/nag/push in etc etc etc. Never underestimate the power of a piece of paper for a generation who were brought up to respect authority!

The other possible side effect of one of the many drugs Dad is on is that it could alter your mood. I’m staying at my folks house tonight for moral support and I can honestly say that this drug has altered Dad’s mood….he was treating his sick bowl as a fashion accessory. My Dad has always been a little off the wall, in fact his party trick when I was a kid was to drive the car with his knees and no hands, but I’ve not seen him in a playful mood in ages. Obviously having the chemo and taking some step to fight it is a good thing, for now.

I was slightly wired all day today, I was up in London for a meeting, and I felt so far away if anything had gone wrong. That said it was a good meeting and nothing did go wrong and Dad is insistent that I don’t put my life on hold for him. Having been home for most of March, unfortunately I have stacks of travel planned in April. If I’m truly honest I’m absolutely dreading what the next few days and weeks hold. That said everyone who has dealt with Dad over the past few weeks has done so with such kindness, that it makes me feel reassured and humbled, and a little more daunted (because my suspicious mind assumes that this is a sure fire indication that this really is coming to an end now). I’ve also been blown away by the number of you who have left blog comments, sent tweets or DMs and those of you who text me when I was silent to check how things were going. Thank you all so much. I know it’s hard to know what to say or do in this situation, I know that some people would just rather not think about it, and I know that I am a walking, talking, ball of emotion at the moment and I’m not the easiest person to deal with at the best of time. Thank you all for your patience, virtual hugs and moral support, it’s really appreciated. I’ll leave you all with the man himself modelling an NHS sick bowl!

Santander customer service #fail

Last night as I was busy enjoying @PizzaCafeNewton and watching the Apprentice Final, I received a phonecall on my landline. The conversation went as follows:

Me: Hello

Caller: Hi, it’s Ben (cant remember his proper name) calling from Santander. Just to let you know this call may be recorded for training purposes.

Me: Uh huh

Caller: Can you confirm the first name of your address please

Me: Um, could you tell me what you’re calling about please

Caller: Um, I need you to confirm your address details first, they’re DPA requirements. I’m from Santander.

Me: Sorry Ben, I’m not sure I’m that comfortable confirming my details to you

Caller: Why not, it’s DPA requirements…Data Protection Act

Me: Well, yes, but I’m still not that happy with it. You called me, how do I know who you are (while really thinking I’d rather be enjoying my evening)

Caller: I’m Ben, from Santander

Me: Yes I know you say you are, but I don’t know that. I’m not that comfortable to be honest

Caller: *Long loud huffff* Oh well I can put something in writing if you want

Me: Yes please, that would be great, thanks.

Am I missing something here. I get called at home, by a bank, requesting my details – when I say no, they don’t even offer a number I can call them on (not that I’d particularly trust that either). Not sure whether it’s spam or just shite customer service but I’ll live without knowing what I’m missing for now.

End-of life care

End of life care is something of a focus for me at present. For anyone who has not read my blog before my dad has terminal cancer, Dan a close friend of mine died of a brain tumour a year ago and I also have two elderly grandparents who at 91 and 93 (next week) are likely to need end of life care or support some time soon. In my professional life it has also been a focus of late as there has been a government programme focusing on End of Life Care, that launched in July 2008 and there have been a number of resources and publications aimed at improving standards across health and social care published recently.

Last night I steeled myself to watch the episode of Dispatches that had aired on Monday evening, Secret NHS Diaries – you can catch it on C4OD for the next month. It featured three people towards the end of their lives and the experience of them and their carers as they tried to have the death that they wished for. I’ll not go into great detail – would urge you to watch it yourself if interested, but I thought I’d offer a few reflections on the programme and the reaction it evoked for me.

Watching the programme just reminded me of what an epic experience we have ahead of us as a family! I saw my mum briefly today and she’d recorded the programme but didn’t feel able to watch it just yet. I’m not sure whether I want her to watch it or not really, my mum has a good grasp of what (potentially) lies ahead but there is something quite stark about watching someone going through the battle of learning to accept and let a loved one go. Lynn Pinner talked about how she wasn’t ready for Harry to die – even when he was tired and claiming he’d had enough. This was the point when I broke my seal and the tears started – it is agonizing to see her so desperately not want to let go and yet to also see her loving husband not wanting to let her down. I know that my mum wouldn’t in any way want my dad to suffer, she has said as much and they’ve discussed it – that said, I’m not sure at what point you give someone permission to stop fighting, to let them go. This was part of my argument in my last blog post about cancer treatments and patient milestones.

Lynn and Harry also seemed to get trapped in the bureaucracy of the system – Harry had a heart attack, was provided with morphine and care by the Ambulance Service and Lynn was left to contact and arrange a morphine driver with the District Nurse Team. Simple – or so you’d think, but the exasperation shown  by Lynn as she tried to arrange a visit from the District Nurses brought a really strong feeling of deja vu. In my experience District Nurses have always been fantastically caring, efficient and professional when I’ve come into contact with them….getting hold of them however is never that easy. I can identify many occasions where my mum or myself would have been waiting for the nurse to come visit dad, only for them to not arrive when planned; this would result in phone tag and more waiting and usually eventually someone would come. I have no doubt that the DN’s providing them with support were doing their best but to someone dying who needs pain relief the fact that the day/night shift was coming to an end is irrelevant – it strikes me as ridiculous that in this day and age when you can bank, eat and shop 24hours a day, you can only be fitted with a pump to give medication during a day shift!

I also shed several tears for Tamina Rasheed who talked and filmed the struggle to ensure her father, Ken, received the best care within hospital. Her story rang true to me, there have been several occasions where I’ve had to advocate for my dad; never have I doubted the ability or intention of the staff who provided him with care – just with their capacity to do so in an effective manner given how tight time and resources are. My experience in life, that also appeared to feature on the programme, was that one of the challenges for staff across the NHS is being able to communicate and make decisions with each other – I can only imagine that this is more of a challenge when everyone has more to do and less time to communicate.

The thing that struck me the most in the programme though was the way in which the patients and their carers or friends had to fight – you just don’t have the energy to fight a system when someone close to you is dying and you shouldn’t need to. For what it’s worth I didn’t think the programme was very balanced, it didn’t offer any experiences of people receiving good support at end of life and I know it exists, my friend Dan died a dignified death and the support his wife and three year old daughter received was brilliant; neither did the programme offer any explanation or context of the constraints on the professionals providing the service. It failed to really provide many answers – to be fair maybe that’s not the point of it – but as someone who is living this challenge at the moment I’d like to have seen some more balance or positives presented.

On that note the following resources published last week might be of interest to anyone working to support end of life care:

> evaluation of End of Life Locality Registers – locality registers allow key information about someone’s preferences to be recorded and accessed by a range of services

> a guide to achieving quality end of life care in domiciliary care

> a practical guide about achieving quality end of life care for people with learning disabilities

Service recovery: customer, process and employee

This is the third instalment of my experience with Virgin Media and so it might not make sense without the back story; if you’re interested in that you can read Virgin Media – the best and the worst, which details what happened over the Christmas break with my lack of broadband and the response from the @virginmedia twitter team, and you can also read my attempts to make sense of my response to that in Service recovery Virgin Media style.

This post serves two purposes, to update on the response from Virgin Media (in case anyone out there is interested) and to pick up on the really useful comments and insights that the service recovery post led to – thank you to everyone who discussed it with me on the blog and on twitter, your reflections were really useful.

Since the most recent post I’ve had a visit from a Principal Technician, Mark, who phoned in advance to arrange a convenient time, who called to let me know when he was running late and who was incredibly pleasant and (as far as I could tell) knowledgeable when he got here. He has reassured me that if we have any further problems it is due to the network and not our equipment and most importantly he left me his contact details so I could get in touch direct with him if we had any future concerns. At this point in time we’ve had continual broadband, no problems and great customer service. So I feel quite satisfied but a few comments on my last post have got me questioning whether my expectations are too low?

I do think though it is a sign that we see these kind of responses as “awesome, great or impressive”.. I think we have grown to bad Customer Service and our expectations are pretty low…[comment from @wimrampen]

I suppose I agree with Wim, my benchmark for customer service is evidently extremely low. My benchmark is born of my experience though. For example, on Friday evening I spent over an hour on the phone to Orange trying to register a sim card. After 62 minutes of a recorded message telling me my call would be answered shortly, I decided to give up and get on with my weekend and sort it when I return to work on Monday. That is the environment within which I was pleased with the personal touch from the Virgin Media twitter team. On the same post @MartijnLinssen shared his experience with Telfort, his former ISP, he quite rightly observed that seemingly Virgin Media had made the better investment in how they sought to resolve my difficulties.

Wim also warns of relying on myths, something so very true to my own approach, see this post about the need to rely on evidence in the design of services. Wim clarifies:

There is little argument about the Service Paradox, but it should also be clear that this will only work as long as it remain incidents. It is not recommended to implement a service recovery strategy as means to increase Customer loyalty.

I feel the need to take responsibility at this stage for possibly mis-representing Fabian Segelström and Jeff Howard’s post, eek. If that was the case I’m sorry. They in no way imply that Service Recovery opportunities should be created or exploited, more that their resolution leads by lucky coincidence to improved satisfaction over all. In an attempt to right this wrong misrepresentation, and in trying to understand more, I came across a journal paper, Why service recovery fails: tensions among customer, employee, and process perspectives. The findings of this literature review support my earlier hunch that this wasn’t about employee incompetence but more about a dissonance between the people working within a system and the different elements of it:

Findings – It is argued that service recovery often fails due to the unresolved tensions found between the conflicting perspectives of customer recovery, process recovery, and employee recovery. Therefore, successful service recovery requires the integration of these different perspectives. This is summarized in the following definition: “Service recovery are the integrative actions a company takes to re-establish customer satisfaction and loyalty after a service failure (customer recovery), to ensure that failure incidents encourage learning and process improvement (process recovery) and to train and reward employees for this purpose (employee recovery).”

So there you have it, it seems that Virgin Media responded well in terms of my customer recovery and I get the impression that there is some internal dialogue that should lead to process and employee recovery. I only hope so. This was also picked up in the comment left by Guy Letts, his experience was similar:

Clearly there are many individuals there who are competent and who care deeply. Actually that’s usually the case with the individuals – as you rightly point out. I used to run a large support operation and we recruited to a high standard, as many do. It’s the empowerment, the systems and the policies that are often sub-standard – and that’s down to top level leadership not just investment.

As Guy points out, the responsibility lies with top level leadership, so I hope that those who hold that role within Virgin are listening. If they are and they’d like to share that with us, and/or they’d like to discuss any of this further, I’d love to hear from them.

What is service design?

I’ve been playing around with the idea of writing this post for a while, well I guess on and off for about a year! What started as a wish to understand more has, if I’m really honest, progressed into a minor irritation at the lack of clarity and then just before Christmas I had a phone conversation with Mike Baldwin where I found myself attempting to both define and defend/promote service design as a discipline. Mike was asking great questions; now I’m a little biased and think that Mike is a) one of the good guys b) intelligent and interesting and c) questioning and not ready to just accept an opinion without some substance to back it up. Mike is interested in health and value, he is also interested in research, evidence and rigour and several of our conversations have focused on health care and improving services, drawing heavily for me on my Dad’s experience of cancer, you can read more about that here!

Anyway, when I talk to Mike I realise I’m not the only person who is sceptical and looking for proof when it comes to service design. In fact maybe Mike is, like me, a service design agnostic! I’m not going to recount all of the conversation or questions that Mike and I were batting around but the starting point was pretty much as follows:

> What is service design?
> How strategic is service design?
> What functions is service design optimising? Is it a focus on efficiency, effectiveness, economic imperatives or something else?

For now I’m just going to focus on my attempts to answer the first question. Luckily for me I’d recently attended ServDes conference (you can read more of my thoughts on that here) and so probably felt as well equipped as I’d done in a long time to attempt to define service design as I’d been exposed to many different views and approaches to it. I’d also debated, discussed and extrapolated in the pub the very essence of what a service designer is, the consensus conclusion being there’s no such thing as a service designer! Those conversations had also exposed me to many of the subtleties behind the belief that defining the discipline limits its development – more of that below.

Perhaps most importantly though I had a secret weapon! I had in my possession a brand new shiny copy of This is Service Design Thinking which is available to buy now from the publishers and which I’ll blog about soon – it’s ace, go buy it. TiSDT was launched at ServDes and consequently a copy was given to each attendee at ServDes as a gift I’d already skim read most of it and devoured the opening chapter from Marc Stickdorn (Marc is one of the two editors – along with Jakob Schneider) and so I was confident he’d have the answer.

TiSDT definition chapter opens as follows:

If you would ask ten people what service design is, you would end up with eleven different answers – at least.

Service design is an interdisciplinary approach that combines different methods and tools from various disciplines. It is a new way of thinking as opposed to a new stand-alone academic discipline. Service design is an evolving approach, this is particularly apparent in the fact that, as yet, there is no common definition or clearly articulated language of service design.  [Stickdorn, 2010, 29]

Marc goes on to explain their decision not to just define service design; this is based on an acknowledgement of the need for a common language alongside the concern that by imposing a definition the discipline is in some way being constrained or limited. TiSDT offers a number of different views of what service design is with definitions from a number of institutes, industry bodies, academics and design agencies. What is then provided as a really useful starting point are five principles of service design thinking. Service design thinking is: user centred, co-creative, sequencing, evidencing and holistic.

To set my stall out I think TiSDT is great, I love my copy, I think it has a wealth of information and ideas within it and has already helped me to have confidence to introduce service design to people and defend it when questioned. It introduces a number of fields of activity that implement a range of service design thinking, these include product design, graphic design, interaction design, social design, strategic management, operations management and design ethnography. Each of these fields have a chapter where they are briefly introduced and their relationship to services specified. For me this is really useful stuff. I do however struggle with the notion that defining the discipline would somehow limit it. TiSDT includes a quote from Buchanan (2001) that implies defining design would potentially lead to lethargy or death of the topic in hand and Marc offers the same concern “A single definition of service design might constrain this evolving approach”.

**Disclaimer** At this stage I had a really useful conversation with @fergusbisset – thanks Ferg. He nudged me in the direction of reading Buchanan’s paper for myself and also warned me about opening a can of worms that had seemingly settled down. I understand from him, from some of the people I spoke with at ServDes and from Buchanan’s writing that many hours have been spent on these discussions already, therefore continue this post with a little trepidation. I’m not wanting to rake over old ground but I have yet to find the answer I’m after and have not been involved with the discussions to date, so bear with me

To me Buchanan makes a far more balanced argument than the use of the quote in the book implies. In fact he follows his statement with the following:

However, I believe that definitions are critical for advancing inquiry, and we must face that responsibility regularly in design, even if we discard a definition from time to time and introduce new ones. [Buchanan, 2001, 8]

Buchanan addresses the purpose and use of definitions, classifying them as descriptive or formal. Descriptive definitions, as pointed out by Buchanan, are incredibly useful for acknowledging the influences on a discipline – TiSDT is great at doing this, throughout the book many descriptive definitions are offered and many insights can be gained from that. As I said earlier this is incredibly useful, especially for someone without formal design training or knowledge.

Descriptive definitions also tend to carry emotional weight, they are great for describing what something is or isn’t (stating the obvious I know), but I think for those of us who are more comfortable with an academic or research approach or who are seeking a more formal definition or who simply wish to present a pragmatic, rationed argument as to why they should invest money in something, a formal definition is required. Buchanan offers the following formal definition of design:

Design is the human power of conceiving, planning, and making products that serve human beings in the accomplishment of their individual and collective purposes. [Buchanan, 2001, 9]

Buchanan situates his definition within Aristotelian causes. Human power is the agency of action, conceiving, planning and making the final cause – the end goal that design is focused on, products (in the broadest sense) are the outcomes, the formal cause and accomplishment of individual or collective purpose is the material cause, as human needs, activities and aspirations provide the subject matter. If this definition is adopted the scope of application is pretty much universal and as wide ranging as it gets – I’m absolutely convinced that this could be adapted and used as a formal definition for service design, without limiting it’s potential.

But why do I care? I think by failing to offer a formal definition, rather than limit the development of the discipline by applying unnecessary constraints and restricting creativity, my concern is that there is a risk that the discipline is being limited by its inability to communicate it’s value and worth in a way that different audiences can understand.

Where does all of this leave me, and I imagine Mike? Well we’re not designers but we are interested in the potential of service design. We have an interest in science – physical and social, economics, psychology, health and social care, research and rigour, evaluation and value. We are both also interested in ethics and how these are addressed. It was no coincidence to me that many of the concerns and questions that Mike was raising in our conversation were ones I’ve questioned myself many times before:  how do we know if service design is ethical and/or safe? how can we identify a good service design practitioner? is service design essentially just marketing? is service design essentially just ethnography? is it about aesthetics or something more? what is the relationship between service designer, client and end user? what evidence are policy makers using to decide on the role that service design can/should play? is there clear evidence that it works? how does service design represent uncertainty? what is value and how do we know if service design will bring good value for our organisations?

As I said at the start of this post, I feel that there is a value in looking at the design of services. I feel more confident now to try and articulate that value – in no small part with thanks to ServDes, TiSDT and conversations and questions with and from many people especially @fergusbisset @segelstrom @designthinkers @grahamhill @adamstjohn @rufflemuffin @mrstickdorn @iterations and of course @mikey3982. I would however still like to see a formal definition that I can readily wheel out when someone asks, even if in time it becomes outdated or unhelpful. For now I have the beautiful This is Service Design Thinking that not only contains a wealth of information but also dazzles anyone who looks at it by it’s layout and design….thereby convincing them of the value in and of itself; maybe that’s it, maybe @jakoblies work on TiSDT and the resulting beautiful aesthetically appealing design is actually all that is required, I guess time will tell, they certainly help

I’m sure that I’ll come back to these thoughts as I continue to try and incorporate elements of design and thinking around designing services into my own professional work, so I’d really welcome your thoughts, reflections and any definitions that you find particularly useful. Thank you for taking the time to read this epic post.

Service recovery Virgin Media style

Last night I blogged about my experience of Virgin Media over the Christmas break, you can read the full story here, but in a nutshell my broadband connection kept failing, the information I was given was incomplete and/or incorrect and I was bloody frustrated at missing the online shopping opportunities presented by the Christmas sales! I was also very pleasantly surprised at the brilliant customer service I got from the staff on the Virgin Media twitter team.

Today I’ve been very surprised and impressed at the response, which has included:

* The lovely Virgin Media twitter tweam sent me a thank you for my post and let me know it’d been passed on to other people to try help learn the lessons

* Alex posted a comment on my blog post acknowledging that it had been read and lessons would be learnt

* Two people who I follow on twitter who work for VM got in touch with me personally to apologise on behalf of their company – this was a really lovely touch, they had both offered to help out before and I was impressed with their pride and sense of disappointment that VM had delivered such a mixed service

* Then this afternoon I got a phonecall from the local Field Manager, he explained what had been done the last time a technician came out and that they’d checked the signal levels today and offered for a Principal Technician to come out and run a health check on the circuit (all sounds very New Years Health Kick to me) externally and internally to our property. Bob explained that the Principal Technicians have more sensitive equipment and should be able to rule out whether there are any ongoing, underlying faults on the system. This has been arranged for Saturday so I don’t have to take any further time off work and they are going to ring first thing on Sat and let me know roughly what time they’ll be here – to save me waiting in.

* Alongside all of those responses from Virgin Media, I also got quite a lot of chat and banter on twitter more generally. In amongst the general chat was a link to a post about the call centre script by @Martijn Linssen – couldn’t have put it better myself so I’ll not try, I’m sure you’ll recognise the problem; Guy Letts and Martjin have also been engaging in a fascinating conversation about ‘incompetence masquerading as innovation’, you can read more here on Martijn’s blog post Social Customer Service – Proving you failed?

Photo by Gene Hunt

All of this got me thinking about what is really going right and wrong here and I thought I’d offer my thoughts to help out the VM people trying to learn the lessons!

Is it about staff incompetence? I don’t think it’s that simple. I know that VM have something very right – the people I talk to who work for them, the people who evidently manage their twitter account, even to some extent the technicians we’ve dealt with – they’ve all shown an ownership of the Virgin Media brand and it is evident that they can give great customer service – within the constraints of the system in which they work. I’m not sure if this was clear enough in my earlier post – I’ve been very impressed with (most) of the individuals who I’ve dealt with about this matter – I just think that they could have done better if they were empowered to do so, if they weren’t following a script of options, if they weren’t limited by the equipment they had available; my sense is that this is a problem with the design of the service not necessarily just poor customer service.

Does Guy’s hypothesis stand? Is this incompetence masquerading as innovation? Again I don’t think so. The technology is new, the problems are old, but the response is something different. I feel that social media allows for a different type of response, my issue was that I didn’t have enough information and that I didn’t feel like my concern was understood – the twitter tweam were able to alleviate that, even though the underlying problem has yet to be guaranteed to be resolved. Problems will always occur, services will always break down but the response is what is different here. Add to that they really were taking on board what I was grumbling about – the suggestion that they would ring on Saturday with an estimated arrival time was brilliant, leaves me a little more in control of my weekend; if only that was routinely possible.

My sense is that Virgin Media have responded brilliantly….I consider that I’m lucky in that my grumble was picked up on twitter, if it had been my non-twittering mum experiencing the same problem I’m not sure she’d have got the same response or be as happy as I am, but then I guess less people would likely hear about it. A few months ago I blogged about a small problem I’d had with the awesome Pizza Cafe Newton and their brilliant response. Fabian Segelström read that post and later used it as an example of good service recovery. So what is service recovery I hear you ask? Rather than reinvent the wheel I’ve quoted from Fabian and Jeff Howard’s blog post about it:

…research has led to four major findings on how service failure and subsequent recovery affect customers’ loyalty towards a service company:

1. Service failure has a negative effect on customer loyalty intentions.
2. Failure resolution has a positive effect on loyalty intentions.
3. Customer satisfaction with the recovery has a positive effect on loyalty intentions.
4. Outstanding recovery results in loyalty intentions which are more favorable than they would be had no failure occurred.

Whereas the three first findings could be expected, the fourth is somewhat of a surprise and has become known as the service recovery paradox. The service recovery paradox means that a customer might be more satisfied with a company although they didn’t deliver on their first attempt than if they had delivered the service without errors, if the recovery action is perceived as very good.

Fabian points out that current estimates are that it costs five times as much to attract a new customer as it does to retain one; at this point in time I feel that Virgin Media have done all they can to resolve my problem – with the responses I’ve received today I feel like they 1) care and 2) might get to the bottom of it, so I guess at this point in time I am one of those rather random customers whose loyalty intentions might improve as a result of the failure I’ve experienced. For now at least. I think it’s about investment, illogical as it feels to put up with a deficient service, attempts at service recovery mean that I now feel like we’re in this together, it’s no longer my problem it’s *our* problem, in fact this feels like a joint investment between me and the best bits of Virgin Media.

Ultimately the proof of the pudding will be in the eating, if the problem continues and it can’t be found out why then I will have to look to move to another service provider, but at this moment in time my broadband is tickety boo and my loyalty to Virgin Media unquestioned. So again, thank you Virgin Media and thanks to Martijn, Guy and Wim for stretching my thinking on this one. Thanks also to Fabian and Jeff for doing the research leg work – nothing like some evidence informed thinking about the design of services.

Virgin Media – the best and the worst

Like most people I was really looking forward to my Christmas break away from work, a chance to chill out a bit, unwind, step away from the to-do list and just generally recuperate. Life has been a little hectic of late and I was really looking forward to spending some down time, getting up late, slouching on the sofa, surfing the interwebs, chatting on twitter, online sale shopping – I’m sure you can picture the scene.

Photo by preoccupations

Unfortunately for me Virgin Media had other ideas. Early in December our broadband connection stopped working, a phonecall to a Virgin call centre in India meant being talked through various tests – turn the modem on and off, reboot things, cross you fingers, wish on a star – you know the drill. No joy meant that a technician was booked to come out and fix it. This required someone to be home to let the technician in and they couldn’t come until the day after next. To be fair to Virgin at this stage they refunded the three days that we were without service. By some miraculous trick the interwebs magically mended itself the day that the technician came along so he had nothing to do but leave his mobile number for any further problems in the next fortnight. So far so good.

So when the broadband connection went down again the week of Christmas I wasn’t too concerned and just assumed that the Virgin Media fairy would wave her magic wand and all would be well in the world. However this wasn’t the case, I couldn’t get time off work at such short notice so couldn’t take the first available appointment and agreed to wait in for the technician on Dec 28th – even I wouldn’t begrudge the VM technicians a holiday but it did mean I couldn’t get the sale bargains I had my eye on Tuesday 28 Dec saw a different technician – who came in, replaced all the equipment (all of it, couldn’t even test it) before telling us what we already suspected that the problem was something external to us (the first time the problem occurred was very snowy, the second time the snow had started to thaw and we suspected it was something outside as nothing internal had changed), he went down the street to an external box (where there was a problem with the points), changed the connection and left reassuring us all would be well. No mobile number given this time – too busy I guess.

For a brief sojourn connectivity was restored, aimless tweeting was engaged in, sales shopping done, christmas emails exchanged, facestalker perused and blogging engaged with. It was fantastic – nothing like a period without internet to make you really appreciate it when it’s back. Only problem was that the new found love for VM was very short lived….by the next morning it was dead again.

You get the picture at this stage – phonecall to Virgin, a Scottish lady called Shona answered – she was very polite while seemingly completely unable to use any discretion – so I explained the situation and that it had happened twice already this month and that the problem was external, she followed her script – insisting that we turn everything off, follow the tests so she can tell me that the problem was external. Grrr. She was terribly sorry but we’d have to wait until the following week to see a technician as they were short staffed over Christmas. My plea to Shona was that however long we waited please could she ensure that someone came who could actually diagnose/fix the problem rather than just treat the symptom – I’m not sure she understood what I was getting at but she wouldn’t budge. So I hung up and bitched to my twittersphere (via my mobile) about the lack of value Virgin Media seemed to place in my time and the lack of concern about solving the problem.

Drumroll please, cue superhero music….in stepped the Virgin Media twitter team. This was Virgin Media at it’s best, they asked what the problem was, offered to help, asked for my details and phoned me, I wasn’t available so they phoned me back ten minutes later. The guy I spoke to was lovely, agreed that they would now ‘own’ the call which meant they could coordinate it and get it sorted. They promised to get me back online as soon as they could but more importantly they genuinely understood the inconvenience and they cared about it….well to be true I don’t know if they did care but it felt like they cared! There was no script, there was banter and empathy, a human response. All was OK, I understood them and they understood me, we could be friends. The VM twitter team worked their magic and arranged a technician to come out the next day between 8-1pm. This would be the third day we’d had to wait in for Virgin but it didn’t matter, we trusted it would get sorted.

The next day I was like an excited kid waiting for a visit from their favourite friend I was up, showered and decently human at 8am just in case the technician stopped off at ours first. 9 o’clock came and went, 10am, coffee at 11am, baked gingerbread and thought the technician could have gingerbread and tea. 12 noon came and went, 1pm….you know that feeling when you’re waiting for a date to turn up but you just know they aren’t going to come. Well yeh, that! At about half one I tweeted my disappointment, the VM twitter team were on the case, they’d try find out what had happened.

Eventually at about 3.30pm I got a phonecall from the technician who had been the time before….he agreed that it was a problem external to our home, he explained that there was no need for me to wait in, I’d wasted an entire day, he didn’t need to come into the property at all because it wasn’t a domestic problem, it was a network problem. Unfortunately the network team were out sick so there was only one guy covering all the surrounding area. I chatted with him a bit and in the course of about a five minute conversation I heard excuse after excuse – the team were out sick, Christmas meant they were too busy, the call centre put notes on but no-one reads them – when questioned on this he claimed his system didn’t allow him to read the notes of our job until it was due otherwise he’d have let me know hours ago not to wait in. He explained how his equipment doesn’t work and he can’t test certain things so he just has to replace everything, then he mentioned that apparently we’re different to the whole of the rest of the country and the call centre just don’t understand the system here. So in a nutshell I’d wasted an entire day and if I was lucky, and he could get hold of networks, and networks weren’t overwhelmed then there was a chance they’d swop out the amp in the box down the road and hey presto the magic would do its work. I took his number (once he remembered it) and he promised to call me back once he’d spoken to networks and let me know what was happening. I’m still waiting for that call. I’m guessing networks did their job and for that I’m grateful. I now have broadband and the VM twitter team were awesome and sent me a tweet to check all was sorted. I guess for now we’ll wait and see how long the solution lasts but it took three days of my life and pretty much took the shine off my Christmas down time.

I understand there are busy times at work and that people get sick and that systems don’t work brilliantly, I understand that the people in the call centre are following their scripts and can’t make autonomous decisions. I also understand that as a customer I don’t want to hear excuses, I want someone to take ownership and to relate to the inconvenience. I’m tempted to bill Virgin for three days of my time wasted resolving this but luckily the twitter team did a good enough job that I’m calm for now, because I felt listened to! My letter to Richard is still in my drafts folder, instead I wanted to shout loudly about how awesome the twitter team are and thank them for their contribution to improving my Christmas. Thank you @virginmedia.

ServDes: value, trust, transparency, ethics and shared expertise

A couple weeks ago I had the absolute pleasure of attending ServDes, the Nordic Conference on Service Design and Service Innovation. Held in beautiful Linköping in the middle of the South of Sweden (Swede’s seem intensely proud of which bit of Sweden they’re from so I thought I better clarify that), the research conference was focused on ExChanging Knowledge. Acknowledging that most publications in the field of Service Design have focused on establishing the discipline, the call for papers for ServDes was an explicit invitation to those in research and practice who wished to contribute to developing the service design knowledge base to:

“…openly discuss challenges of the field. Changing Knowledge is about investigating the fundamentals in service design and challenging the knowledge inherited from the disciplines which service design has grown out of. Exchanging Knowledge refers both to integrating knowledge from other fields and the ongoing conversation between conference participants with their various roles; consultants, students, in-house, clients and academics”

The full conference programme, linked to all the papers presented, is available on the conference website. Better still you can view videos of all the presentations on the conference Vimeo site. The conference kicked off with an unconference day; myself and Fergus Bisset hosted a room exploring Evidence Informed Practice in the Design of Services. You can read our session outline here and we’ll report the day in another blog post shortly. I really enjoyed the day, we met some fantastic people with a range of views and we had some great input from people on twitter who weren’t able to be at the conference….but more on that later.

For now I wanted to just offer a few of my highlights, thoughts and reflections. I’m sure these will develop over time and more blogs will follow but this post in itself is way overdue now so I wanted to put this out there as a starting point. I have chosen to just offer random thoughts, grouped where possible, but not linked to the conference programme in any structured way – partly because I prefer chaos, partly because I’d like (at some stage) to comment on some of the papers in more detail and partly because it all merged into one amorphous collection of thoughts in no small part influenced by the pre-servdes chats and the learning and conversations outside the conference proper. When looking through my notepad of scribbles and drawings from ServDes I found a napkin on which I’d scribbled a bullet pointed list of the key terms and phrases that seemed to emerge throughout the conference – the top four for me were value, trust, transparency and shared expertise. As good a place as any to start methinks.

Value – what a biggy. Value came up again and again, with reference to the value of service design as a discipline and of design more generally. Katarina Wetter Edman reported her (PhD??) study on value in design, you can read her paper here. She referenced Graeber’s four (anthropological) perspectives on value: the concept of doing good, value in a monetary sense, value as meaning and meaningful difference and value as action. WetterEdman’s research found that designers don’t talk about value, not as an explicit concept, the v word was rarely mentioned with a preference given to talking about emotions, contextual understanding and helping others. Within that, designers tended to focus on value in use and/or economic benefits – the real challenge of this perspective of course is that value is a value-laden and individualistic perspective (apologies for stating the bleeding obvious) and therefore how designers understand and share ‘value’ is key to success.

Value is without doubt key to judging what the outcomes of good service design are. It struck me time and again at ServDes when I asked people why they were interested in designing services or what service design is (I’ll come back to that in a later blog post), that almost everyone made reference at some point in their answer to wishing to do good or to the fact that they wanted to make a difference. I admire, respect and whole heartedly support anyone’s intention to do good or make this world a better place – however as genuine as I am in that sentiment, I am also incredibly wary of the damage that good intention’s can do when left without recourse or measure! This may all sound terribly worthy (and at some level you’d be correct to view it as such) but in few other professions would young graduates be given free reign and direct contact with people relying on services without any support, checks or balances – personally I think this is less of a concern when relating to someone’s experience of their supermarket shopping trip than raising their hopes about their ability to influence their lives, their community, their health service or something else of significance for their future.

In my opinion one feature common to both the concept of value and the intention or wish to do good is ethics. Without a consideration of ethical standards I’m unclear of how anyone can have confidence that they aren’t doing harm, or indeed that they are making a positive difference and doing good. The topic of ethics came up a few times at ServDes – probably more in the informal break and lunch conversations than in the papers, we discussed it in our EIP unconference and Sarah Drummond made reference to it in her case study presentation, building on some of our earlier conversations and some topics we’d thrashed around the night before. Sarah was reporting the Getgo Glasgow case study and drawing on her experience gained through her Masters studies, you can read her blog post about it here. Sarah’s blogpost that followed her presentation drew heavily on Don Norman’s post, Why Design Education Must Change, which deserves a blogpost in its own right to continue the conversation. Don’s post complements the unconference discussions we were having around the use of evidence in design, he states:

Science is difficult when applied to the physical and biological world. But when applied to people, the domain of the social sciences, it is especially difficult….Designers, on the whole, are quite ignorant of all this science stuff. They like to examine a problem, devise what seems to be a solution, and then announce the result for all to acclaim.

I’ll discuss this further in a later post but would like to think that the time is coming when designers will freely, openly and confidently discuss the ethical implications of their work. Which brings us on to trust and transparency. I’ve been digging around trying to learn more about service design for just over a year now; the notion of designing for services make sense to me, I am certain that service and experience of service is as, if not more, important than product – my interest is in the journey, not just the outcome, and yet I was tentative about attending ServDes. In part this was because I had followed the SDN (Service Design Network) conference in Berlin from a distance, dipping in and out on twitter, and was even more sceptical about service design at the end of it. Throughout that conference the twitter stream was predominantly self-promotion, lots of patting on the back, lots of bigging each other up, very little critique, discussion or reflection – obviously I wasn’t there but from the outside I was left underwhelmed and sceptical about the value of attending ServDes!

For those of you reading this with an understanding and unquestionable belief in service design I’m sure this may come across as quite harsh or unduly cynical, however I consider myself to be a service design agnostic – I’m just waiting for more proof! I was a little nervous about how I would find ServDes and how open people would be to discussion and debate, to questioning and challenge. It is fair to say the whole conference experience far exceeded my expectations from this regard; I met some fantastic people who seemed equally ready to have these discussions and I think some were even seeking them (that or they were all just exceedingly polite with me). I found a humility about service designers which on the whole I had not felt before – maybe that is what comes from immersing yourself in someone else’s discipline, maybe it was the effect of people being able to be honest and let their guard down (in the absence of many clients), maybe it was an environment created by the explicit focus of the conference on openly discussing challenges in the field or maybe it is just the stage in development that the discipline is at, I’m not sure which but I was blown away by how honest (some) people were about not having all the answers. For me there is a real need for trust and transparency – designers don’t have all the answers, none of us have all the answers, so the earlier we admit that the easier things are. From what I heard at ServDes there is very much a focus on multi-disciplinary working and/or gleaning tools and techniques from many different established disciplines and for this to be successful, people need to be honest. To build successful and ongoing relationships between customer and client, between designers and users, people need to trust each other and be transparent in their dealings.

Which leads on to my final reflection about shared expertise. In my experience to date in life, most progress is made working in a team, with a range of people who between them hold a broad spread of skills, abilities and approaches. I can’t imagine that successful design is any different. There is an absolutely solid evidence base about what factors help and hinder multidisciplinary working and lead to best use of shared expertise. Common challenges are around identifying a shared starting point, a common language, a way of working and creating an environment where people feel able to question the status quo and admit when they don’t have the answer. ServDes was a great success for me in this regard – the designers, marketeers, students and academics I met were all open to my alternative approach, in fact I felt very welcomed into the conference (no small achievement for someone with a below par starting point, a different professional language – evidence anyone?, and an irritatingly challenging approach to learning new stuff – which is a glossy way of saying if I don’t understand something I tend to ask too many questions); I very much hope that the conversations that were started at ServDes – both in person and through twitter – will continue to develop over the coming months.

A massive huge TACK to everyone from the Cognitive Science Dept at Linköping University who arranged ServDes; to all the volunteers and especially to Stefan, Johan (on the left) and Fabian (on the right) for the very generous Swedish welcome and the awesome conference.

Evidence Informed Practice in the Design of Services

I’m currently sat at Stockholm train station en route to ServDes – a service design and innovation conference taking place this week in Linköping. Tomorrow myself and Ferg are running an unconference session, we’re hoping to talk to people there about what they consider evidence to be and how they use it in their practice. Obviously this is related to work, but it’s also a genuinely fascinating question. Last week we started asking people on twitter what evidence meant to them. The responses we’ve had can be seen here, they’re great, really diverse and wide ranging. If you’d like to take part please feel free to tweet with the hashtag #servdeseip what evidence means to you. We’re hoping to tweet the session tomorrow so be sure to check the hashtag or our twitter streams @georgejulian or @fergusbisset to see more.

You can learn more about the conference, including some of the other unconference sessions outline over at http://www.servdes.org – there are some really interesting sessions, I’m a tiny bit disappointed that we are running a session and can’t join one of the others! You can also see the main conference papers here and check out the snow on the webcam here.

Our session outline follows – please do join in.

What we would like to share with you?

We hope participants will be interested in debating what counts as evidence, sharing how they use evidence in their own practice as well as discussing the ethical implications of not using evidence as part of their professional practice. This discussion will offer insights into how we can all best use evidence to improve our professional practice and to support the design of services in a way that will measurably improve people’s lives.

In true UnConference style we do not want to present or structure the day too much, presenting you an opportunity for discussions specific to your own sector and the use of evidence in your own practice.

Is this session for you?

We hope that people will feel able to drop in and out of our session (Room 5) and offer their input throughout the day. Our only request is that you come with your own views and experiences and are willing to share them – we are looking for debate and discussion and do not claim to have the answers ourselves. We do not expect anyone to have any specialist knowledge about evidence, research, health or social care or even design…but if you have an enthusiasm for reflecting on your own experiences and those of others or experience and interest in the way people evidence their personal and professional practice and experiences, we’d be delighted if you joined our session at some point throughout the day.

What do we do?

We are both currently involved in promoting the use of evidence-informed practice in adult health and social care in the UK at research in practice for adults. With a focus on knowledge transfer and knowledge creation, co-production and knowledge exchange, ripfa offer an eclectic range of approaches and organisational experience in empowering people to understand, create and use evidence. We would happily introduce these and specifically the Change Project model, an innovative method for applying research, building research capacity and empowering both personal and organisational behavioural change.

How to participate

If you are at ServDes please do come along to see us in person, otherwise please do get in touch via twitter. We’re going to be using the Twitter hashtag #servdeseip, so feel free to follow that or check in occasionally on our mini-site http://www.ripfa.co.uk/evidence-informed-practice-in-the-design-of-services/latest-updates/. We will update the mini-site with the preparations for, progress of and reflections from the Unconference session.

Who are we?

Ferg is a social designer with a particular interest in motivation, behaviour change and winter sports; George is a former academic and researcher with a passion for evidence, honesty and cake.