INTEGRATION OF EVIDENCE-BASED AND EXPERIENCE-BASED DESIGN: CONTRIBUTIONS FROM A STUDY IN A HEALTH CARE SERVICE INTEGRAÇÃO DO DESIGN BASEADO EM EVIDÊNCIAS E EXPERIÊNCIAS: CONTRIBUIÇÕES DE UM ESTUDO

The purpose this paper is to present an integrated study of Service Design and the Mechanism of the Production Function (MPF) for redesigning the health care services to improve the perceived value of the patient and increase the productivity of hospital operations by eliminating wastes. The method used was action research and applied in an ICU of a private hospital in southern Brazil. The techniques of participant observation, interviews, archival research and meetings co-creation with a team of the hospital were used to collect data. Data were analyzed through content analysis of the interviews and the Design Service and Production Engineering tools. Evidence based approaches tends to contribute to the replication of the project outcomes in future cases. The MPF can support project development in the field of Design, as well the integrated approach developed in the healthcare sector, helped to devote more time to the phases of diagnosis and implementation. The findings are useful to demonstrate that can use simultaneously approaches the Service Design and MPF for the development of more robust solutions in health care environment. Further research could be done in other private or public hospitals as well as in other hospital units besides the ICUs. Limitations include the work done in a single hospital and service unit, data collected from a small group of people in the hospital. Integrating Evidence-Based Design, Experience-Based Design and the MPF can produce a more robust way to justify and define the focus of improvements in health care services.


INTRODUCTION
In several countries, Economy is moving from material basis (manufacture) to immaterial basis (services). As technological development increases, access to both supplies and information, as well as to convergent technologies, lead to a servitization of goods. Trends involve the concepts of product-service-systems and mass customization, among others. This context of service infusion in Economy correlates to an increasing on the rigor about what users consume. As Lockwood and Walton (2008) state, in this context, consumers' requirements demand a stronger differentiation effort. And companies see the offer of services as an opportunity for enabling emotional bonding with their brands through customization. As a consequence, areas focused on designing creative solutions for brands and products start to focus their attention on the development of methodologies able to delineate the offering of services aligned to the value or experience desired by the end consumer, enabling new ways of service development (FREIRE and SANGIORGI, 2010).
In a particular perspective of services, Healthcare can benefit from such new ways of value focused service design. Along time, Hospitals have been trying to deliver more efficient, effective and valuable services. In this context, value is not restricted to profit, but to the intent of maximizing the benefit/cost relation. For this, there is a continuous emphasis on studies about how these services can be modified or improved (GRAZIER, 1999;ARREGUY-SENA et al., 2001;SILVA et al., 2006).
According to Rottingen et al. (2009), applying Design on Healthcare must consider a sum of elements of experience, like performance, engineering, and aesthetics. In such view, the medical emphasis on evaluations and evidences should inspire service designers not only to create processes, but also to demonstrate the impact by them generated, through data and evidences, to inform decisions (past evaluations), and to improve the practice (future evaluations). Bate and Robert (2006) investigates possible ways of using Design for reforming the Healthcare system, aiming at a large-scale change. Their study is based on applied case analyses looking to the different perspectives a Service Design (SD) project can take, aiming to propose more effective solutions for this sector. Evidence-Based Design (EBD) and Experience-Based Design (ExBD) are highlights in such context. EBD is a research line that tries to "revolutionize the way how design is applied" and increase its quality level (BRANT et al., 2010). ExBD, on the other hand, has, as main goal, turning the service or the product experience unique and better for the user, starting from his or her involvement in the Design process (BATE and ROBERT, 2006).
Both EBD and ExBD approaches present remarkable benefits, as they also present limitations for their isolated appliance on the healthcare context. Aggregating both approaches seem to present a relevant path (CARR et al., 2011)  This paper discusses the advantages of using an integrated approach SD+MPF in the healthcare sector. The discussion is based on an action research developed in an Intensive Care Unit (ICU) of a Brazilian reference hospital. The study was focused on the operations performed by the nursing technicians', once these professionals interact more frequently with patients and their relatives/visitors, as well as perform the major part of the tasks in ICU flow. These subjects create positive or negative bonds with the patients and their relatives, and frequently notice a problem before any other member of the team.
Literature search on the EBSCO database reveals an apparent lack of academic work, whether theoretic or empiric, integrating SD, OM/IE and healthcare. From the featured index, considering peer-reviewed publications from 2002 to 2012, only three works (WYE, SHAW and SHARP, 2008;VAN STAA et al., 2009;CARR et al., 2011) congregate such themes in the same sense intended in this research. The work of Carr et al. (2011), which examines the potential integration of EBD and ExBD approaches to develop creative solutions for the services of a healthcare organization in England, it the one that best aligns to the goals of this paper. In their study, the authors describe that the EBD approach supports interpreting protocols and guidelines with a quantitative emphasis, while ExBD allows considering specific requirements of both the patient and the context. The use of the patient's point of view as a key-concept in SD adds value to the contemporary efforts for improving healthcare processes, considered the benefits of integrating quanti-qualitative methods. In such sense, Bate and Robert (2006) defend the research of different approaches for SD development, as an evolution of the way in which changes happen. This includes the evolution to more patient-centered services in Healthcare.

Service Design on Healthcare Systems
According to Bate and Robert (2006), the areas of Healthcare and Design share the common goal of making something better for their users: a "good design" of a healthcare service is not necessarily different from a good project in any other area.
And it must contemplate three aspects: (i) performance -how much the product or service fulfills its function, which, regarding the healthcare context, means how efficiently the work of treating and taking care of the patients is done; (ii) engineering -how safe and well designed is the product's engineering, or, regarding services, its delivery (without damages or errors, with consistence, durability and confidence); and (iii) aesthetics -how good is the experience, how the user sees it and feels well while interacting with the service or using the product.
The association between improving healthcare's processes and services and improving patients' experience present a relevant topic of research with practical application. According to Ericson (2009), every healthcare experience is formed by a collection of interaction systems. The Center for Healthcare Design has analyzed more than 600 researches and has demonstrated a straight connection between the patient's health, the care service's quality, and the healthcare design (LEE, 2011;ZIMRING, 2004). Much has had been written about the operational, technological, diagnosis and health treatment structures. Nevertheless, the emotional systems end up being less explored. Next to the tangible elements are the expectations, the perceptions, the motivations, the behaviors and the decisions. Thus, three key-actors have to be considered in a so-called healthcare emotional system: the patient, the doctor, and the patient's companion (relative or friend). The patient occupies the central position in this network, thus effective experiences must be projected to provide the appropriate information, to give a sense of control, and to create an atmosphere of care and confidence for these actors (ERICSON, 2009).
In the same context, Zimring (2004) stresses that finding methods to improve patients' answers, their safety and satisfaction, as well as workers' retention and service's efficiency is key for a well-designed healthcare service. Bate and Robert (2006) confront this view, stating that focusing solely on the user and ignoring necessities and interests of the internal workers is giving a step back, because the emphasis must be on co-design, in involving providers and receptors of the service. Lovlie et al. (2009) also state that, despite information and knowledge are central elements in healthcare, a user-led approach has limitations, opening space for data and indicators to inform decisions (past evaluations) and to improve the practice (future evaluations).
As in a knowledge intensive field, the quality of the healthcare services provided depends directly of the effectiveness and commitment of each employee who has contact with the patient. Training, knowledge sharing, collaborative work and collective willpower converge to create cultural change. Large scale changes in healthcare organizations do not necessarily depend on external conductors, but on the ability of connecting and mobilizing people, creating a bottom-up movement for development and change (BATE et al., 2004). In such sense, Bate and Robert (2006) defend intensifying the search for "better" and more efficient theories and approaches for large-scale changes and for the transformation of the systems as a whole, especially those with participatory purposes.
Among the possible existing theoretical approaches to treat SD in healthcare systems, ExBD and EBD present as alternatives (CARR et al., 2011), as presented in the next section.

Evidence-Based Design and Experience-Based Design
Evidence-Based Design (EBD) emerged as an approach to improve Design's quality and capacities. EBD focuses on creating more useful and sustainable products and services and making designers search for scientific methods as a way to improve the project's results. At first, the evidence-based concept implies that project's demands can come up from scientific evidence, obtained most of the times by academic research, risk-benefit analysis or meta-analysis of a series of studies.
Generally, the goal is the improvement on either quality or risk management of a service, product or process (CARR et al., 2011).
In the same sense, Brandt et al. (2010) point out that design professionals depend typically on intuition and personal experience to make choices during the project process. Decision making, thus, works on a certain level, but is limited to selfknowledge and self-experience. EBD proposes the use of investigation, computer simulations and other techniques to predict possibilities and reduce costs, as well as to collect data during creation, to convince the stakeholders about investment and test the prototypes quantitatively. Evidences are necessary to understand how specific Design strategies can affect products', constructions' or services' performances, in order to develop forecasts.
According to Zimring (2004), EBD in healthcare services can: (i) increase the patient's safety, reducing risks of infection, wounds due to falls, and clinical errors; (ii) eliminate environmental stress factors, like noises, that negatively affect patient's responses and workers' performance; and (iii) reduce stress and promote cure, making hospitals more pleasant, comfortable and welcoming for patients and workers. Carr et al. (2011) analyze that, in practical terms, EBD is frequently used on a large-scale projects as to build hospitals, as part of management and evaluation, and tries to standardize the procedures to guarantee predictable patients' responses.
On the other hand, Experience-Based Design (ExBD) consists of two main elements: (i) the participative involvement of users in the Design process; and (ii) the experience, focusing on the improvement of service or product experience as a whole, concerning how the client perceives it. ExBD focus on improving the product or the service through the user's eyes. The nature of the change is based on understanding the experience in a profound level, always keeping in mind that it involves the subjective physical, sensorial, cognitive, emotional and aesthetic aspects, and knowing how to use these can create more successful and complete services than before.
Customers have a type of knowledge that other involved actors have no access to, once they are the first to experience the product or service intending to effectively use it, so they have special insights that can help making the service better in the future (BATE and ROBERT, 2006). Carr et al. (2011) alert that radical tools are necessary to perform the transforming change on services and there are no evidences that small-scale studies referred as ExBD have the power to influence or boost radical transformations. The comprehension of the factors that contribute for a more complete user experience at a large organization is a complex process that involves management systems and processes that many practitioners of ExBD do not consider.
Due to the benefits and weaknesses of basing design only on the user's experiences or on the evidences of the service, integrating these two approaches seems to be a way for improving the SD methodology. The effectiveness of the EBD approach lies on the provision of protocols and processes for the success of interventions of the project, but it lacks of overall effective engagement of stakeholders interested in interpreting and translating the guidelines on the local context. On the other hand, the tools and methods developed by the ExBD approach can provide a counterpoint to these prescriptive approaches, increasing the specificity of the standard through a profound comprehension of the local user's experience, favoring the participation of all the interested ones in reflecting about the current experiences with the service, imagining alternatives and being part of the process's redesign (CARR et al., 2011). This bottom-up approach has proven to be more effective in promoting behavior changes in the individuals and, when combined with the EBD systems approach, offers an integrated perspective that can provide the ideal environment to conceive and, effectively, implement proposes of redesign services in the health environments.
Due to the complexity of fields such as Healthcare, this integrated approach seems to be particularly interesting (CARR et al., 2011). Following this integrated view, standards and process' systems, concepts that have been dominating the field of healthcare services for almost a decade, would need to stay next to aesthetics and subjective matters, considered simultaneously, never as isolated elements (BATE and ROBERT, 2006). The central point of this approach in the current context is that hospitals should not only turn the real treatment safer, but also make the patients feel safer. In this approach, still there is a great necessity of process mapping, care service programs development, and other traditional and well-established methods and tools (BATE and ROBERT, 2006).

The Mechanism of the Production Function
The concepts of 'operation' and 'process' are central to the field of OM/IE, regarding performance, structure and efficiency of production or service systems. Shingo (1996) argues that all productive systems can be understood as a functional network of operations and processes: (i) the processes follow the material, customer, This concept allowed Toyota to create a series of concrete actions for improving its productive system performance, supported by the other concepts such as productive losses, standardization, pull-production and autonomation, among others (OHNO, 1997;SHINGO, 1996). The orientation for processes, as a means for getting better results, is other fundamental element to understand Toyota's culture: the right processes will lead to the right results (ANTUNES et al., 2008). The main goal of improvement projects is thus eliminating wastes during the processes (LIKER, 2005).
For performing significant improvement on the production process, it is necessary to distinguish the production flow (process) from the subject flow (operation), and analyze them separately. MPF's allows identifying seven wastes connected to the process and operation functions. Five wastes are related to the process function: overproduction, stock, waits, processing, and transportation. Two other wastes are mostly related to the operation function: internal movements, and fabrication of defective products (SHINGO, 1996). Elimination of these wastes must be a priority, in order to systematically reduce costs and improve productiveness.
Improvements made on operations without considering their impacts on processes can, in fact, produce a local operational efficiency, but not a global operational efficiency (Shingo, 1996) and a better relation between profit and investment.
By analyzing the healthcare environment from the perspective of MPF, it is possible to apply the concepts here briefly presented to identify sources of wastes in healthcare processes (Table I), as well as analyzing the impacts of actions focused on improving such processes (SILVA et al., 2006).  Shingo (1996)

METHODOLOGY
This study follows an exploratory orientation, based on the Action Research strategy. Thus researchers and key participants are involved in a cooperative and participative manner, having an active role in collecting data and solving a collective problem (THIOLLENT, 1997). The Action Research approach enables both SD and MPF analysis, marked by the openness and the participation of researchers and insiders, providing knowledge that can be processed into information through the analytic background of EBD and ExBD in the context of the particular healthcare organization. This strategy implies that results cannot be generalized, even they can lead to particular decision making as well as they can serve as contribution for a base of cases from where emergent patterns can raise.
The ICU has 32 beds to assist severely ill patients and attends a monthly average of 114 people, being divided in three categories of treatment complexity (High, Medium and Low).

Stage 1: Diagnosis
This stage lasted five months and consisted on the application of a series of tools that allowed the researchers to evaluate the point of view of the nursing technician regarding the object of study. In parallel, analyses of the client's value perception were conducted under the perspective of the assistant doctor, since this professional is responsible for referring the patients for the ICU. Based on this analysis, three possible focuses for the project were identified ( Figure I).
Data collection was followed by a six-hour continuous immersive observation (shadowing) representing the complete workday of the ICU's nursing technicians.
Video and audio recordings, and field notes about the researcher's perceptions during the data collection activity were used to collect data. The focus during the recording was to observe behaviors, structures involved in the activities, relationships and processes the nursing technician had contact with during the work shift. The focus was not properly to diagnose issues, but to observe the technician's difficulties and to produce insights of possible solutions for improving the observed activities. The processes and associated wastes were also observed, such as inadequately projected activity flows, reworks during the workday, unnecessary movements, among others. Interferences from and relations with other colleagues activities that make the technicians add less value than they could.
The percentage of value added by the technicians' work was mapped, based on the principles of the MPF (SHINGO, 1996), aiming at analyzing the technician (object of the flow) and the subjects that act in time and in space, highlighting improvement actions. The obtained results are presented in Table II. The involved team focused the SD + MPF project on the duty transitions among technicians. Despite this process was judged as fundamental for most of the actors considered on the research, it was performed informally. Also, the following reasons were presented: (i) high potential impact on the operation with lower effort, according to Senge's (1998) principle of leverage; and (ii) duty transitions are a critical matter for the nursing area (SILVA and CAMPOS, 2007).

Stage 2: Creating and Thinking
The creating and thinking stage lasted three months, comprising the activities presented in Figure   The refined prototypes were then presented to the ICU's management team for assessment, adjustment and approval. A total of 3 versions of the checklist were developed. Version 3 was officially sent to the Medical Registers Committee of HDM, for formal approval. The new Vital Signs Sheet was also appreciated by the ICU's management team, but its implementation was not recommended by the managers for the following reasons: (i) it contains patients' control data and its implementation affects all ICU's processes, which would be too complex for the project horizon; (ii) the current Vital Signs Sheet is a formal document archived by the hospital, for proving the administration of the treatment and external actors can also have access to the registered information; (iii) it would depend on a specific approval of the Medical Registers Committee. This shows the difficulty of implementing changes in the Healthcare context, especially when it straightly involves control and care of the patient's health.

Stage 3: Implementation
The implementation stage was carried out during 4 months. A synthesis of the steps followed in this stage can be observed in Figure

ANALYSIS AND DISCUSSION
The global process of SD is open and cyclical and allows interventions throughout the process (MORITZ, 2005). During the conduction of this research, the main influences from the perspective of the evidences for the global process of SDaligned with the perspective of using MPF concepts, from OM/IE -were the constant concerns of: (i) conducting a replicable method for new studies; and (ii) searching for "scientific evidences" for sustain the actions taken throughout the project. SD, when based on experiences, has the goal of demonstrating a particular cultural reality as best as possible, considering the client's value perception as part of that context (CARR et al., 2011;BATE and ROBERT, 2006  This value maps structure contemplates an "affective structure" to support the actors. Differently from other corporative contexts, in Healthcare contexts the actors frequently deal with matters of insecurity, lack of control, embarrassment, struggle between life and death and, because of that, they demand more Psychology-related structures. The externalization of such perspective as proposed in the structure presented in Figure V allows focusing SD on such dimension, thus leading to a potentially more robust approach. On the same sense, integrating SD with MPF concepts provided focus on evidence collection and supported the prioritization process of improvement proposals of the SD project. It also kept the focus on a process perspective present, hierarchizing tactical and operational actions. The MPF concepts provide a different perspective from the SD, not dividing the system into physical evidences, but into a network of processes and operations, independently analyzed to diagnose wastes or errors that determine the core of the problem. Considering the observed context, each contact point or identified process unleashes several internal factors that are essential to the patient's care. In this sense, many key operations can be diagnosed and re-projected in a more suitable way if considered as parts of an integrated process rather than independently -specially those related to the care of the patient and his or her safety. If SD provides a more horizontal and broad perspective, MPF contributes by bringing a vertical perspective of focusing on improvements that mitigate the root causes of problems. The analysis of the ICU technician's wastes during patients' care and the separation in processes and operations, more than in contact points, created a deeper and more measurable focus for the SD project ( Figure VI): the diagnosis becomes improving the management process of technicians' duty, not just the communication of the material support; the checklist was a way to standardize management and control the process. The study also allows understanding the impacts of cultural change can be, when implementing improvements on Healthcare. ExBD can support such analysis by providing tools considering empathy and engagement of the involved employees (BATE and ROBERT, 2006;CARR et al., 2011). According to Biehl (2007), it is necessary to consider the moment of the project in which the users' engagement occur, because, if it does not happen during the early stages, it can lead to the project's failure, for the people will develop resistance and it will become an obstacle. According to Somers and Nelson (2001), Murray and Coffin (2001) and Yang et al. (2006), insufficient training and engaging of all involved users can be an error that echoes negatively on the implementation. So, to integrate evidences and experiences in a project for a hospital sector, a project model should reserve a longer time for the diagnosis (in which there is a global approach based on experience and a justification of the focus based on evidences of the processes) and for the implementation (in which the focus must be on experiences for a cultural change and on the evidences for planning the change management and the results measurement). This proposal is illustrated in Figure VII.

FINAL REMARKS
Developing a Design project involves answering the question "what to do?" (CELASCHI, 2007). What can lack of answers under the client's or manager's perspective is the question "why doing it?". MPF is based on quantifiable evidences and seeks for improving the added value of a process by eliminating unnecessary operations and processes. Integrating SD and MPF can produce a more robust way to justify and define focus of improvements. Therefore, it is possible to determine that a Design project will be made with, say, an "X" focus, because it has a very high loss index, rework or waste is above the goal etc. This logic helps to justify the "why" After, when the "how to" has to be determined, come Design tools, creativity and so on.
Despite the potentially positive results obtained in the described application, limitations must be considered. The application in this specific context does not allow understanding the trade-offs and complexities associated to applications in other of their activities. Other actors could bring different or deepen evidences of the analyzed context, influencing the proposed approach described in this paper. In the researched context, patients were mostly found unconscious or with no condition of evaluating their experience with the hospital service. On a contrary situation, in which the patient found him or herself lucid and conscious, the Psychology sector of the hospital would be of great importance, because it would be possible to get information related to the patient's perceptions based on evidences and experiences, something that was not possible to evaluate with this research.
In the Healthcare context, being guided only by the patient has no use. It is necessary to involve other actors on the creation of the service. Healthcare is a specialized knowledge intensive area, making mandatory the direct involvement of collaborators, and the implementation and creation stages to happen almost simultaneously. At the same time, the study allowed to infer about the importance of planning the change process management, and of evaluating the changes during the implementation, so that the organization could converge towards the change. People will engage in what they helped creating and it can be either a bottleneck or a leverage point for a successful implementation.
The proposed SD+MPF conjoint approach can help finding evidences for changes on a hospital context demonstrated to be productive. Future work include replicating the research approach in other public and private hospitals, to compare contextual similarities, differences and their influence over the obtained results, as well as, creating a base of case evidences, for refining the proposed approach and its ability of promoting change.