[ARCHIVED V2] Revamping the national end-of-life planning program strategy

OVERVIEW:

Service design project to refresh the national program strategy and artifacts for an omnichannel end-of-life care planning experience that empowers self-initiation. Proposed design strategy was adopted by government regulators (Ministry of Health and Agency for Integrated Care) of the national Advance Care Planning (ACP) program. Two prototypes - a Convo Kit and a Digital Documentation Flow - are also in development.

METHODS:

Interviews, Observations, Usability Tests, Artifact Review, Co-design

DURATION:

7 MONTHS

2022.08 - 2023.03

ROLE:

Researcher, facilitator, service designer on team of 3

DELIVERABLES:

Research insights, design strategy, design principles, prototypes, service blueprints and journey maps

Jump to: Context • Methodology • Discoveries • Outcomes • Reflection

🌰 In a nutshell…

Phase 1: Understanding

How do Advance Care Planning (ACP) conversations and documentation happen currently?

💡

• Conducted interviews and observations to map current client journey • Broke down client journey into 4 processes and focused on exploring self-initiation in 2 of the processes for this project

Phase 2: Testing

How well do existing artifacts support self-facilitation and self-documentation today?

💡

• Conducted usability tests of existing artifacts to establish baseline ability to self-initiate planning • Derived insights to guide prototyping and co-designing

Phase 3: Co-designing

What kind of artifacts and programs would support a self-initiated planning process tomorrow?

💡

• Co-designed a Convo Kit, a Digital Documentation Flow, and a brand new program strategy with stakeholders • Handed off prototypes and development roadmaps in formats that stakeholders could easily access

Context

We were tasked to design for a shift from a formal facilitated process of end-of-life care planning to a self-initiated process.

In Singapore, Advance Care Planning (ACP) (external link) is a form of end-of-life care planning. It involves holding and documenting conversations with your family about your healthcare preferences in case you are no longer able to communicate your wishes.

OLD: ACP discussions were mostly initiated by healthcare providers, and clients had to attend a facilitated discussion with a trained facilitator.

NEW: Encourage middle-aged Singaporeans to self-initiate this reflection and conversation with their families when they are still healthy, before it’s too late.

A doodle I made of the ACP process today, and the envisioned future.

❤️

I requested to be a part of this project shortly after my grandmother passed away. The project was equal parts challenging and healing. Ultimately, learning about the stories in this space made me an even stronger advocate for end-of-life care planning.

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Research Methodology

Phase 1: Immersion

How do ACP conversations and documentation happen currently?

Aug 2022 - Oct 2022

Interviews and Observations
Interviewed 10 clients who had completed their ACPs, 2 Nominated Healthcare Spokespersons (NHS), and 4 facilitators
Observed 3 facilitated discussions and 2 facilitator training sessions
Conducted a kickoff and a insights workshop with stakeholders

💡

I designed the interview and observation guides with the project lead, and we each led a few client interviews. I also co-facilitated the workshops.

Phase 2: Testing

How well do existing artifacts support self-facilitation and self-documentation?

Nov 2022

Usability Testing and Artifact Review
Invited 5 participants to complete the existing workbook and the existing form independently
Asked 3 facilitators how they would probe for more information based on the client’s inputs
Artifact review of documents, workbooks, and educational materials across US, UK, Canada, and Australia

💡

I led the artifact review independently. We designed the usability testing guide and facilitated the interviews as a team.

Phase 3: Co-designing

What kind of artifacts and programs would support a self-initiated planning process tomorrow?

Dec 2022 - Mar 2023

Co-design and usability testing
Co-designed Convo Kit with SMEs
Conducted 4 playtests with 3 families and a group of game designers + stakeholders
Co-designed digital documentation flow with UXDs from the legacy planning team
Co-designed program strategy over 3 workshops with stakeholders

💡

I designed the playtest guides together with the project lead, and led the stakeholder playtest independently. Thereafter, I generated development roadmaps for the Convo Kit to handover to stakeholders. I also co-facilitated the stakeholder co-design workshops.

🗣

Participants were recruited through our stakeholders and through our organization’s social media.

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Discoveries

Phase 1: Immersion

How do ACP conversations and documentation happen currently?

Clients go through 4 stages in the current planning experience - these translated into 4 distinct “self-initiated” processes.

💡

We spoke to actors involved in the process - clients, nominated healthcare spokespersons, and facilitators - and observed how the facilitated conversations happen. The goal was to map the current client journey so that the team could align on opportunities to design for self-initiation.

One of the participants we spoke to.

“I am single so no one to talk about this with - if I tell someone they will be very upset - ‘don’t talk to me, spoil my dinner.” - A participant sharing about the difficulty of broaching this subject with loved ones.

“Then I realised I don’t have anything to be counselled because I don’t have any death threatening disease. Am I mature enough to do that… I made the decision to plan simple first. So I downloaded this pdf kit.” - A participant who reflected using the available workbooks, as she did not feel ready for a facilitated discussion.

Finding #1

Currently, a lot rests on the back-and-forth between the facilitator and the client to discuss preferences, make edits, get signatures, and submit the document.

Finding #2

The facilitator is discussing and documenting the client’s preferences all in one session, creating tradeoffs between the functional (documentation) and qualitative (discussion) goals of facilitation.

Finding #3

Clients are already employing various channels to kickstart their planning - over text, Google Docs, or online workbooks

💡

I noticed 4 distinct processes in the current client journey - hence, I broke down “self-initiation” into “self-education”, “self-documentation”, “self-facilitation”, and “self-submission” to help scope our work. We focused on self-facilitation and self-documentation in the next phase of research as these were the heaviest tasks that a facilitator currently takes on.

I made a graphic to reframe the idea of self-initiation into 4 phases: self-education, self-documentation, self-facilitation, and self-submission.

Phase 2: How well do existing artifacts support self-facilitation and self-documentation?

Clients need coherence in the reflection to documentation process, and timely prompts to get to a depth of personal understanding.

💡

Before jumping into designing future artifacts, we needed to understand where the baseline ability to self-initiate is. We decided to run a usability test using existing materials by asking participants to complete the reflection workbook and form on their own, and bringing their inputs to veteran facilitators to ask how they would facilitate a discussion based on the inputs.

A research participant using the existing workbook to reflect and document her care preferences.

“The form… (frowns) it is colder.” - A participant commenting on the difference in tone between the reflection workbook and the ACP form.

“Maybe this booklet can be done directly before they fill in the [form], maybe an official procedure that you fill up the booklet and you get some score, the booklet should guide the form.” - A participant commenting on the disconnect between the workbook and form.

One of the facilitators I interviewed about how they would facilitate a discussion with a client based on what was written in the workbook and form.

“Ya because, unless it’s linked, seamless, tick already here so this one will appear. Otherwise you after the fill up already then you give them the form, they will think that this one [booklet] already have the information, this one serve a purpose already, why would I need to fill up here” - A facilitator addressing the gap in the current materials.

Finding #1

Make it easy, but not too easy - clients worry about whether they’re doing the checkboxes on the workbook “right”.

Finding #2

The current materials serve different needs, so the language and level of detail are vastly different, creating a disconnected experience when completed as a flow.

Finding #3

An experienced facilitator aims to capture the client’s personhood in the actionable future plan.

💡

I realized that the facilitator does three layers of probing to understand the personhood of the client before translating that into an actionable plan. This meant that future artifacts to support self-initiation must not just provide a coherent reflection-to-documentation experience, but help clients get to a depth of personal understanding that allows for future action-planning.

A diagram I made that illustrates the 3 levels of probing that a facilitator does within a conversation with a client.

Phase 3: What kind of artifacts and programs would support a self-initiated planning process tomorrow?

Using earlier insights, we co-designed a Convo Kit, a Digital Documentation Flow, and a program strategy with subject matter experts and stakeholders.

💡

We employed provotyping - prototype as provocation - to elicit mental models around the idea of self-initiation, so that we could distil principles that the program strategy should be built on.

Co-designing the Convo Kit with SMEs

In order to learn more about what would help clients and their families get to deeper understanding and alignment, my teammate designed a scaffold of a Convo Kit that helps individuals facilitate conversations with loved ones.

💡

Using the scaffold, we co-designed with SMEs - a facilitator, a medical social worker, a doctor, and a design student who had worked on a legacy planning project. We leaned heavily on their domain expertise to build the content of the kit.

Co-designing the kit with SMEs.

Play-testing the kit via role-play with our stakeholders and game designers.

We iterated on their inputs and ran 3 play tests with families. I also led a play test with our stakeholders and game designers, kicking off the session with a round of animal charades to help stakeholders take their “serious work” hats off, and create a more light-hearted environment for role-playing family members.

A mother-son dyad who tested the game were able to talk about hypothetical medical scenarios by discussing what other family members experienced, but had difficulty saying, “I would prefer this or that”.

💡

The testing uncovered the need to contextualize reflection questions, concerns around education and accuracy, and tracking the quantity and quality of self-facilitated conversations.

Co-designing a Digital Documentation flow that supports reflection

My project lead took charge of this prototype exploration, consolidating our research into 4 design principles. We co-facilitated workshops to handover this workstream to the design team in charge of MyLegacy, the core digital legacy planning platform of Singapore’s government digital services, to consolidate the various legacy planning tools and minimize redundancy in our work.

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I used what I had learned from the interviews and usability tests to build wireframes that explored prompts for thoughtful reflection.

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After the team at MyLegacy built a mid-fi flow, we uncovered stakeholder concerns around privacy, legitimacy of drafts, and the tension between education and influence.

Co-designing the new program strategy with stakeholders

Initially, our stakeholders believed that introducing self-service tools into the current customer journey would be sufficient for self-initiation.

It was critical for us to help them see how the concerns that the provotypes uncovered needed to be addressed at the program structure and success metrics level, to truly support their vision of self-initiation.

💡

Therefore, we facilitated workshops to co-design the new program strategy with them. It allowed them to fully engage with the necessary policy and regulatory shifts and strengthened their buy-in for the refreshed strategy and prototypes.

For some of our stakeholders, this was their first time working with stickies and sharpies.

I drafted a service blueprint after the workshops to help align stakeholders on the touchpoints we had discussed (graphic remade). Full version viewable here.

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Outcomes

We convinced our stakeholders to look beyond tactical changes at the touchpoint level, and become bolder with innovation at a program strategy level.

We presented roadmaps and strategic shifts to program leadership, consisting of policymakers, senior doctors, and palliative care professionalCns.

For the working team, we prepared service blueprints and toolkits in Google Slides and Sheets, as they were less familiar with Figma and Miro.

One of our final handoffs to co-design the multi-touchpoint client journey of tomorrow.

A snippet of the Far Future service blueprint in Google Sheets.

The ACP Convo Kit prototype is being adapted into a workbook, a physical game board, and an online experience.

I prepared a research and development roadmap for stakeholders that laid out next steps for development and suggested timelines.

Iteration that was handed off to stakeholders for further refinement.

The Digital Documentation flow is being integrated into the national digital platform for all legacy planning matters.

The product team is currently revamping the online documentation flow (external link), using design principles derived from this project.

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Reflections

Process

Strategic empathy for stakeholders

As government regulators, our stakeholders were naturally cautious when approaching new ideas that differed from current policy terms. We had to find a balance between pushing for innovation and adequately addressing their very valid regulatory concerns.

I learned the importance of intentionally building trust at the working team level. My team lead would deliberately create safe and playful spaces for idea exploration before dialing back to more “realistic” ideas. We also delivered artifacts in formats (e.g. an updatable journey map in Excel instead of Figma) they can easily use to communicate with their management.

Prototypes as design provocations

I picked up provotyping through this project, and saw how effective it was at eliciting participant and stakeholder mental models. These findings helped us to sharpen our design principles to inform the overall program strategy.

Personal

Leveraging past experience

This project was a culmination of my research, analysis and stakeholder management skills, coming together in a service design context. As the only member on the team to have worked in a government Ministry, I was able to apply that contextual knowledge to help my design teammates understand and navigate the bureaucratic processes that our stakeholders go through.

Levelling up

I really got to hone my qualitative research skills through this project too. It was a deeply sensitive topic, and I learned from my project lead how to hold space within interviews for people’s deeply personal and emotional experiences. I also got to attend the Copenhagen Institute of Interaction Design’s service design intensive in the middle of the project, which was timely!

Our Service Design cohort, taught by Fabio Sergio (Managing Director, Chief Design Officer, Design & Digital Products Practice Lead, Accenture Song ICEG) and Roberta Tassi (Author of Service Design Tools, Founder and Design Director, oblo).

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