Soft service design outside the envelope of healthcare

Abstract

Better alternatives to improving population health have been sought by healthcare policymakers and the front-line clinicians who see patients in everyday care settings. While public health experts and primary care clinicians recognise the significant effects on health from social determinant factors they have limited tools for addressing these causal factors in their patients' lives. Systemic improvements to a population's social ecology are considerable challenges from within the envelope of a healthcare system. In mental health and primary care contexts, systemic factors, social determinants of wellness and illness (such as environment, housing, social lifestyle, food accessibility) account for a significant proportion of presented conditions. Social determinants are embedded in a community setting, are multicausal and interrelated, have indeterminate risks and are not typically perceived by individuals as health threats. A community's population and traditional primary providers have few resources for intervening or changing source social causes and contributing factors that diminish individual wellbeing. Without addressing these social sources and determinants through channels other than ensured care delivery, their pervasive influence will persist and will continue to be accommodated as effects in larger healthcare systems. A systemic design approach developed from the theories of flourishing mental health and flourishing societies has been adapted to identify and guide supports for socialising collective health. Flourishing entails individual and family health, the movement toward 'a good life', and ultimately the sustainment of human and all life. Toward these ends we present a framework for community-centred approaches to facilitate flourishing through the design of soft services. Current cases in university campus mental wellness, and peer health coaching are developed as models for eliciting design principles and approaches that have been effective in interventions in the social systems surrounding practices of care, outside the envelope in which the healthcare system operates. © 2017 selection and editorial matter, Emmanuel Tsekleves and Rachel Cooper.

Full text

38
Theme1
Design for publichealth
9781472457424pt2_p33-382.indd 389781472457424pt2_p33-382.indd 38 1/20/2017 12:46:38 PM1/20/2017 12:46:38 PM

39
3 Services
Soft service design outside the envelope
of healthcare
Peter  Jones
Abstract
Better alternatives to improving population health have been sought by healthcare
policymakers and the front- line clinicians who see patients in everyday care settings. While
public health experts and primary care clinicians recognise the signi cant e ects on health
from social determinant factors they have limited tools for addressing these causal factors in
their patients’ lives. Systemic improvements to a population’s social ecology are considerable
challenges from within the envelope of a healthcare system. In mental health and primary care
contexts, systemic factors, social determinants of wellness and illness (such as environment,
housing, social lifestyle, food accessibility) account for a signi cant proportion of presented
conditions. Social determinants are embedded in a community setting, are multicausal and
interrelated, have indeterminate risks and are not typically perceived by individuals as health
threats. Acommunity’s population and traditional primary providers have few resources for
intervening or changing source social causes and contributing factors that diminish individual
wellbeing. Without addressing these social sources and determinants through channels other
than ensured care delivery, their pervasive in uence will persist and will continue to be
accommodated as e ects in larger healthcare systems.
A systemic design approach developed from the theories of  ourishing mental health and
 ourishing societies has been adapted to identify and guide supports for socialising collective
health. Flourishing entails individual and family health, the movement toward ‘a good life’,
and ultimately the sustainment of human and all life. Toward these ends we present a frame-
work for community- centred approaches to facilitate  ourishing through the design of soft
services. Current cases in university campus mental wellness, and peer health coaching are
developed as models for eliciting design principles and approaches that have been e ective
in interventions in the social systems surrounding practices of care, outside the envelope in
which the healthcare system operates.
Constraining envelopes of community- based health services
The truism of ‘all things are connected’ is readily acknowledged in public health and mental
health. When mental illnesses or impairments arise, such second- order e ects as emergency
accidents, chronic addictions and the neglect of physical health commonly result. Globally,
the literature shows a large and increasing proportion of emergency department visits from
persons su ering from chronic mental health disorders (Baetz etal., 2015 ; Ford etal., 2004 ;
Byrne etal., 2003 ). Ameliorating the sources of these continuing social concerns requires
intervention upstream into community and local social settings wherein initial conditions
9781472457424pt2_p33-382.indd 399781472457424pt2_p33-382.indd 39 1/20/2017 12:47:04 PM1/20/2017 12:47:04 PM

40 PeterJones
40
started and trigger events arise. Awareness and responsibility for personal health and prevention
also take place within the social context. We can identify these contexts as opportunities for
advanced design of community- located services that promote and facilitate better health
outside the envelope of healthcare provision by primary care or acute facilities.
Healthcare services are structured to provide care accorded to specialty and function (e.g.
emergency, ambulatory, chronic care, trauma care). However, the front lines of care– pri-
mary and community medicine and mental health – are concerned with and consumed
by the everyday, immediate and social health concerns across the entire spectrum of health
issues. One of the most challenging concerns faced in service system design, particularly in
healthcare, is the structural inability of a design programme to direct or evaluate changes to
system- level policy. Service design is user- centred and business- oriented, and typically aims
for improvements to customer– patient interactions within a repeatable activity system, as an
end- to- end horizontal journey. Service design projects generally have no mandate to reform
policies de ning the functions of the service system. The scope of service design occasionally
extends to new activities unsupportable by a payer or policy, such as community outreach
or extensive home care for mental health programmes, but until supported by policy these
programmes may be unsustainable. Acomplementary design opportunity arises to identify
and evaluate person- centred social interventions in community settings aligned to regional
and government health policy.
Whether the boundaries of the health provision system are national (e.g. France or the UK),
provincial (Canada), regional- private (India), or a national- private mix (US), the predomi-
nant modes of service delivery are dictated by the constraints of the payer system. Primary
care and mental health services are typically delivered within the traditional ‘provider’ model,
characterised by coverage of patients within a catchment area or insured pool who present
themselves physically for examination, diagnosis and treatment service.
Integration points for social systems ofcare
Systems of care are organised as social services and are subject to changes in policy and funding.
The de nition of healthcare as a service delivery model by design excludes community- based
health support and complementary modes of care. Providers o er clinical services in response
to physically presented symptoms, and for the most part only clinical services are reimbursed
according to policy.
Changes to practice must be validated by supporting evidence, at least with knowledge
from prior clinical cases and up to the gold standard of randomised trials. We present a service
design approach for primary care and mental health that does not change service within the
envelope of clinical practice but instead addresses community and social factors. Along with
social determinants and environmental factors, these contributing factors might appear to be
nearly invisible in the causation of illness. Yet these factors present signi cant opportunities for
elusive population health interventions, and could mitigate the burden of healthcare by treat-
ing foreseeable causative factors in the upstream problem system.
Seventy thousand diagnosis codes for presented illnesses and incidents are distinguished in
the recently institutionalised International Classi cation of Diseases Rev. 10 (ICD- 10; World
Health Organization, 2010 ) used as standard references for diagnoses, procedures and bill-
ing. ICD codes are useful for aggregating descriptive statistics of measured health problems
in a community, based on presentation and diagnosis. They include a signi cant section on
psychosocial problems (health hazards related to socioeconomic and psychosocial circum-
stances) which support epidemiological and public health statistics. The codes also constrain
9781472457424pt2_p33-382.indd 409781472457424pt2_p33-382.indd 40 1/20/2017 12:47:04 PM1/20/2017 12:47:04 PM

Soft service design around healthcare 41
41
the range of the care envelope, in that while social conditions might be identi ed by codes,
only certain codes and procedures are amenable to billing reimbursement by payers, and social
determinants are not among these. In practice, physicians record the codes that de ne the ill-
ness at hand, and even if there might be psychosocial drivers (unemployment or low income,
environmental hazards) these are often rendered secondary and not considered options for
intervention.
The proposed approach in this chapter addresses these upstream, multiple causative con-
tributing factors. From design studies in mental health and primary care, we propose a model
for enhancing the functions of health occurring before and around the envelope of healthcare.
As in public health, we consider the central context that of a person’s community and their
social ecology. This is an immediate and intimate locus of care that is largely inaccessible to
traditional health promotion and disease- prevention programmes.
Science and design research are both discovering, through di ering modes of investigation,
the deeply implicated relationship between social and environmental contexts on health. As
we might seek changes to clinical practice as a result of these  ndings, meaningful evidence
will be necessary to convince policymakers and the research community of the right changes
and situations. The approach discussed in our account presents a design research intervention,
supported by research into behavioural interactions with environments.
A consideration of growing signi cance in healthcare policy and practice is the recogni-
tion of individual illnesses as emergent concerns stemming from unresolved mental health
issues. The extent to which underlying mental and physically symptomatic disorders are
systemically related will perhaps always be analytically ambiguous. Yet emergency physicians
indicate universally that treating presented incidents without attention to mental health
issues fails to treat the patient’s situation, and the probability of hospital readmission is high.
Unfortunately, even treating these patients in the emergency room (ER) may reinforce the
behaviours acted out from underlying mental disorders, as the ER continues to provide a
local safetynet.
Primary care and mental health services continue to be delivered within the traditional
mode of patient presentation, as mental disorders are inaccessible to treatment unless persons
experiencing their pain declare them as such. Emergency and primary care physicians are
well aware of the predominance of mental disorders instigating trauma events and their co-
occurrence with chronic diseases and addictions. Innovative approaches to integrating modes
of care to address mental disorders contributing to preventable or acute illnesses have been
advocated for over a decade (Chisholm etal., 2000 ).
Design for social determinants ofhealth
The relevance of social determinants of health (Marmot etal., 2008 ) to mental disorders is
well known. The continuing health impacts of structural factors and living conditions present
challenges to policy and system change (Carey and Crammond, 2015a , 2015b ) and calls for
better system design approaches. Better alternatives to improving population health have been
sought by healthcare policymakers and the front- line clinicians who see patients in everyday
care settings. While public health experts and primary care clinicians recognise the signi cant
e ects on health from social determinant factors (such as environment, housing, social lifestyle,
food accessibility) they have limited tools for addressing these underlying causal factors in their
patients’lives.
Most design approaches to healthcare also treat health problems in a service delivery con-
text. The exceptions to these models are service design for health delivery in developing
9781472457424pt2_p33-382.indd 419781472457424pt2_p33-382.indd 41 1/20/2017 12:47:04 PM1/20/2017 12:47:04 PM

42 PeterJones
42
countries, supplementing their typically less- developed healthcare systems. In mental health
and primary care contexts, social determinants of health (SDH) account for a signi cant
(but unquanti able) proportion of presented conditions. Social determinants are embedded
in one’s community setting, are multicausal, of indeterminate risk and are not typically per-
ceived by individuals as health threats. Acommunity’s population and traditional physicians
have few resources for identifying source social causes and contributing factors that diminish
individual wellbeing. Without addressing these social sources and determinants through chan-
nels other than ensured care delivery, their pervasive in uence will persist and will continue
to be accommodated.
A systemic design approach developed from the theories of  ourishing mental health
and  ourishing societies has been adapted to guide supports for socialising collective health.
Flourishing entails individual and family health, the movement toward ‘a good life’ and ulti-
mately the sustainment of human and all life. Toward these ends we present a framework for
community- centred approaches to facilitate  ourishing through the design of soft services.
Current cases in community- based senior care, mental wellness and peer health coaching are
developed as models for eliciting design interventions in the social systems surrounding prac-
tices of care, but not within the healthcare system.
Social determinants of  ourishing
Flourishing as sustainability was de ned by Ehrenfeld ( 2000 ) as ‘the possibility that human
and all life on earth might  ourish on our planet forever’. For individual and social  ourishing
we take Keyes’ ( 1998 , 2002 ) research de ning human  ourishing as a composite of qualities
that demonstrate a healthy sense of wellbeing and social integration. These formulations of
 ourishing can be measured by various indicators of qualities, which we might recognise as
output e ects of individual awareness and social activities, not as the sources of  ourishing
themselves.
Flourishing provides an idealisation principle for both mental health (as it is for Keyes)
and primary care (as relevant to SDH). The integrated de nition o ers a normative goal of
public health and health promotion, yet one not achieved through traditional health science
methods and measures. It is a longer- term, cultural innovation within societies that might
be accomplished by signi cant shifts in social norms and community- level communications.
Such movements might be best fostered by a multidisciplinary, systemic design approach, not
a public health intervention approach.
From social determinants to social ecologies
The social ecosystem model of Bronfenbrenner ( 1979 ) is adapted to identify the functions
and initial measures of  ourishing across a social system. Figure3.1 represents this model
as the inclusion of four system boundaries within which an individual interacts over time,
arranged topologically from the microsystem to the macrosystem (in Bronfenbrenner’s terms).
It shares aspects in common with complex adaptive systems (Plsek, 2001 ) or living systems
approaches, yet there are key di erences appropriate to design contexts. Living systems are
considered whole, symbiotic systems with interdependent living subsystems (Miller, 1972 ,
Capra, 1996 ). Here the social ecology presents a series of social systems, each with a boundary
and nested within larger social systems. They are developmental, that is the complexity of each
social system increases with learning through interaction, rather than symbiotically. The whole
9781472457424pt2_p33-382.indd 429781472457424pt2_p33-382.indd 42 1/20/2017 12:47:04 PM1/20/2017 12:47:04 PM

Soft service design around healthcare 43
43
ecosystem is a ected by its parts, but the greater health e ects are found in the interaction of
parts (individuals) within the social subsystems.
Service design proposals draw from the socioecological system perspective (e.g., the
Tavistock tradition of action research), and within the social ecology a social systems perspec-
tive (Luhmann, 1997 , Christakis and Bausch, 2006 ) is taken for intervention design. Social
systems approaches enable design both materially (e.g., artefacts) and analytically (explaining
behaviours at each level of intervention).
Bronfenbrenner’s ( 1979 ) bioecological theory of human development references these
boundaries, within which the research articulations of  ourishing are assigned. Rather than
individual human development, our interest was to locate individual  ourishing (an outcome
of development) in a sociocultural context for better understanding  ourishing for complex
social design.
• Watershed & bioregion
• Natural resource stocks
• Ecosystem actors
• Ecosystem services:
• Process & use flows
• Regeneration flows
• Cultural services
• Work-life satisfaction
• Organisational
• participation
• Measures of success
• Value co-created with
• stakeholders
• Socially responsible
ECOSYSTEM
MACROSYSTEM Cultura
Belonging Macrosystem
National
Identity
EXOSYSTEM
Government
& Institutions
Corporations
MESOSYSTEM Political
Parties
• Equity of access to
• services
• Community livability
• Cultural resilience
• Respect for commons,
• law
• Political participation
• Capacity to satisfy
• essential human needs
• Community care
Neighbourhood
MICROSYSTEM
Learning
Networks
Congregation
Person &
Family School
• Social coherence
• Social actualisation
• Social integration
• Social acceptance
• Social contribution
• Social care
• Social equality
Practice
Community
Workplace
Microsystem
Family
Groups
Voluntary
Clubs
Ecosystem
Organisational Exosystem Community Exosystem
Mesosystem
Self-acceptance
Positive relations
Personal growth
Purpose in life, Meaning
Environmental mastery,
Competence
Autonomy, Self-care
Integrity
Influence
• Cultural flourishing
• Recognising natural
• ecosystem
• Human & non-human
• rights
• Place in the world
Figure3.1 Flourishing in the social ecology
Source :Jones,2015
9781472457424pt2_p33-382.indd 439781472457424pt2_p33-382.indd 43 1/20/2017 12:47:04 PM1/20/2017 12:47:04 PM

44 PeterJones
44
Four nested social systems are shown in proximal (and temporal) relationship with one
another:
Microsystem: The complex set of relations of a person to their immediate containing
social context. For an adult citizen in the community context, this might typically
entail their family and close relations, their workplace and their immediate friends
and social groups. Consistently with Keyes’ ( 2002 ) notion of  ourishing, the measures
and values associated with this level would include individual wellbeing and social
cohesion and inclusion, as de ned previously.
Mesosystem:The meso level is de ned as a system of individual microsystems. This is
not primarily an aggregate of individuals, it is a number of containing social systems
that initiate and reinforce social engagement. The workplace as a system of relations,
schools for younger people and community or service organisations may be typical
in the meso level of ecosystem.
Exosystem:The exosystem level includes the enduring institutions and major societal
references that all individuals within a social boundary would understand as ‘part of
society’. The exosystem entails workplaces and their larger organisational settings,
business networks, neighbourhoods and local government institutions accessible
within the experience of the individual. This is the level of the business model
function, and would be the level at which social and institutional reform practices
are designed for a similar  ourishing societymodel.
Macrosystem:The society and cultures may be described as macrosystems in the societal
 ourishing model. The macrosystem de nes the enduring archetypes and ‘blueprints’
for societal functions that are repeatable across contexts. The macrosystem includes
institutional, infrastructure, media and information structures that are expressed at
the inner levels.
Ecosystem:The  nal system ring necessarily includes the natural ecosystem, which was
not de ned as an in uence or social system in Bronfenbrenner, but establishes an
environmental boundary and inclusive  nal system. While micro- macro systems
can change in value and in uence over time with human interaction, the natural
ecosystem changes both independently of social behaviour and with direct and
indirect human activities as a complex adaptive system (Levin, 1998 ).
Relationship to social determinants ofhealth
The social ecosystem of  ourishing portrays relationships between individuals (personal
health), social and community contexts and social determinants of health. The tension
between microsystem factors of  ourishing (self- acceptance, purpose in life, personal growth),
macrosystem (cultural in uences and  t) and exosystem (community and workplace structures)
factors reveals contradictions between personal agency and structures, which may present
barriers in navigating health concerns. Individuals living within compromised community
circumstances may have limited agency to reorient themselves, and may be unable to locate
the types of resources they might prefer or expect in their personal or cultural knowledge.
Social determinants have a leveraged e ect on persons who are already struggling with a
compromise such as limited or insecure income, fragmented family situations or a degraded
built environment (Marmot etal., 2008 ). The socioecological model suggests that the meso
(social) and other system levels inhibit  ourishing when opportunities for growth and self-
determination remain inaccessible due to structural community factors.
9781472457424pt2_p33-382.indd 449781472457424pt2_p33-382.indd 44 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 45
45
The following social determinants of health are often recognised (Raphael, 2009 ), here
inclusive of at least one uniquely identi ed in Canada (aboriginal status) that may have corre-
sponding ethnocultural status in other countries. These can be mapped to the social ecologies
in Table3.1 , and from a developmental perspective, we could identify a chronological journey
(e.g., a chronosystem) from the initial confrontation of these challenges in the microsystem of
family life, progressing through life and coping with social and educational settings, toward the
eventual independence and worklife.
Societal factors tend to accrue over time and the presence of one may aggravate another or
all. An individual born into a poor household (1)may be faced with low social status (2)and
barriers to better education (3)in many cases. Aboriginal status (5)and social and physical
environments (6, 7)compound these relationships and contribute to mental and physical
health problems at earlier ages and in greater proportion than in communities with fewer
SDH concerns.
Social factors can erode mental health, even if speci c mental illnesses or corresponding
diseases are not manifested. Health policy acknowledges SDH factors as contributing to poor
health and limiting the e ectiveness of prevention programmes. Social determinants func-
tion completely outside the envelope of healthcare. Clinical (primary) practices rarely address
home and community conditions unless these reveal in critical symptoms. While a service
design intervention might not directly bridge the individual’s community with healthcare
provision, we might realise that such a systemic problem cannot be addressed by episodic or
sequential health services.
Soft service design for campus mentalhealth
An account of soft service design is developed from an action research case of designing
interventions for campus mental health conducted at OCAD University in Toronto. The case
provides a structure for distinguishing design approach and practices relevant to community
health design. Emerging models of public health (Coburn et al., 2003 ; Hepworth, 2015 )
expand the boundaries of public health to populations of concern, addressing the social
ecology from individual wellness to public housing, as in the socioecological model. We adopt
this expansive approach for campus mental health.
The soft service approach re- envisions social determinants in community settings as a sys-
temic situation requiring health services normally considered peripheral or complementary.
Soft services design interventions engage social and community  elds of interaction, with
attention to communicative and passive structural design to in uence preventive health or
Table3.1 Social determinants of health mapped to the social ecosystem
1. Income Exosystem (family, microsystem)
2. Social status Mesosystem
3. Education Mesosystem
4. Employment/ working conditions Exosystem
5. Aboriginal status Microsystem
6. Social environments Meso- exosystems
7. Physical environments Micro- mesosystems
8. Personal health practices and coping skills Microsystem
9. Healthy child development Micro- mesosystems
10. Gender Microsystem
11. Culture Macrosystem
9781472457424pt2_p33-382.indd 459781472457424pt2_p33-382.indd 45 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

46 PeterJones
46
health promotion. Soft service design attends to the open and nearly unlimited range of
opportunities in human lifeworlds for everyday activities accessible outside of the envelope
of health services. It di ers from public/ community health in that meeting health outcomes
or measures would not necessarily be the goal of design, or even a driver. If we are interested
in human  ourishing, a wide range of socioecological frames ( Figure3.1 ) can be considered
its canvases.
The designation of a soft service indicates a situation where value co- creation can arise in a
context outside of the service provision boundary. Asigni cant public investment in medical
or mental health deals with ‘failure demand’, resulting from local socioecological systems that
generate illnesses or critical incidents requiring care intervention. Due to healthcare policy,
payer structure, medical resource availability and cost, such interventions are provided today
as care transactions.
One aim of soft services design is to disclose opportunities for discovery in a popula-
tion’s health commons , proposing designable common resources that positively contribute to
health in a community setting. Ordinarily service organisations or professional services are
made available to health seekers (users) as formal service o erings. Walk- in clinics, emergency
rooms and pharmacies are clearly displayed and made accessible, and commonly branded as
distinct entities. However, clear boundaries or entry points for a speci c service, or for certain
customer, payer or user needs may not be distinguishable. Campus mental health, though
based on a well- de ned population of students and a university setting,  ts this frame. Student
health needs cannot be identi ed by observation, or even data (given privacy laws protecting
health information). Design interventions for engaging and helping students were discovered
as ‘pre- services’, as opportunities for informing rather than direct care. Health interventions
within the campus commons include peer communications, education and locating health
accessibility features.
In this case where no end user can be identi ed (as there is no ‘user’ in the cycle) a bene -
ciary can be re- envisioned as a person in a population coping with everyday health concerns.
We refer to this identity as the health seeker. The health seeker (Jones, 2013 ) refers to a person
as an active agent with conscious and non- aware orientation toward a balance between health
(growth orientation) and entropy (potentially life diminishing) in a situation. This allows us
to represent persons as uniquely, internally aware of their motivations to improve their health,
whether sick or not. The theory of health seeking provides a basis for relating individual moti-
vations and growth behaviours (agency) in the socioecological model. At each system (from
micro to macro) one’s orientation to  ourishing enlarges, from the individual self to the social
and to a community exosystem, where individual  ourishing might be re ected in one’s par-
ticipation in a community. It o ers a qualitative frame for identifying and evaluating changes
introduced in soft services design.
Campus mental health research context
Canadian universities and health policymakers have made signi cant investments in providing
for the mental wellness and emotional health of students to facilitate the educational
mission, campus climate and safety and successful graduation rates. Campus mental health
is a strategic concern, with numerous intervention programmes evaluated across schools
(Popovic, 2012 ). In Kirby and Keon ( 2006 ) over 100 recommendations were lodged by a
Canadian senate committee to inform institutions addressing people living with mental
illness. The central notion that individual recovery was deemed as critical to Canada’s mental
health strategy, de ned as ‘living a satisfying, hopeful, and productive life even with the
9781472457424pt2_p33-382.indd 469781472457424pt2_p33-382.indd 46 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 47
47
limitations caused by mental illness’. This policy de nition is consistent with Keyes’ ( 2002 )
de nition of  ourishing for mental health. The senate committee established the Mental
Health Commission of Canada, whose strategy published six strategic directions for policy
and service development:
1. Promote mental health across the lifespan in homes, schools and the workplace and pre-
vent mental illness and suicide wherever possible.
2. Foster recovery and wellbeing for people of all ages living with mental health problems
and illnesses and uphold theirrights
3. Provide access to the right combination of services, treatments and supports when and
where people needthem.
4. Reduce disparities in risk factors and access to mental health services, and strengthen the
response to the need of diverse communities and Northerners.
5. Work with First Nations, Inuit and Metis to address their mental health needs, acknowl-
edging their distinct circumstances, rights and cultures.
6. Mobilise leadership, improve knowledge and foster collaboration at all levels.
From the socioecological perspective, several of these directions might be met through a soft
services model as opposed to direct therapy model. In particular, the vision for reaching broad
sectors of society with mental health disorders is being challenged by several trends:the
continuing perceived stigma within target population sectors, particularly college- age
males (Eisenberg etal., 2009 ), the lack of knowledge about mental health therapies and
their e ectiveness, and meaningful access and a ordability across the spectrum of mental
healthcare.
Canadian universities deliver mental health services within a traditional clinical service,
with on- campus clinics providing mental health and basic primary care, typically with a full-
time clinical director and part- time physicians and counsellors. Mental health services include
individual counselling, encounter groups, mental health promotion, student follow- up and
medical psychiatric referral.
A National Collegiate Health Assessment survey ( 2013 ) disclosed a higher prevalence of
mental health- related issues at OCAD University, in particular depression and suicide, than at
other post- secondary schools. Our research identi ed several factors believed to contribute
to this  nding:
• sensitivity of personality traits of students choosing art and design education;
• high workload, demanding coursework and associated stress in student environment;
• nature of creative work (to be original, imaginative) places continuing personal stress on
students;and
• intensive critique practices in art and design, with real- time critical assessment of work
by faculty andpeers.
Young adults typically face many signi cant personal challenges in their transition from a
secondary school in their hometown to any residential university. Incoming university
students face social pressures and responsibilities associated with  rst- time independent living,
the developmental challenges of establishing new, adult and institutional relationships, and the
initial formation of personal economics and households. In our research we found a signi cant
additional stress burden on art and design students imposed by the unique academic and
creativity demands.
9781472457424pt2_p33-382.indd 479781472457424pt2_p33-382.indd 47 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

48 PeterJones
48
Design- driven action research
We employed a design- driven participatory action research approach (Swann, 2002 ; Gloster,
2000 ) for the campus mental health study, following a process of iterative planning and
performing studies,  nishing with proposals. Aprior account of the study was published in
2014 (Jones etal., 2014 ).
Over an eight- week period a series of interviews and observations were conducted with
students and sta to build an account of experiences with campus services and mental health
concerns, of clinician and service provider work activities in context. Figure3.2 presents the
structure and relationship of research activities conducted by the team in support of discover-
ing and proposing new service models for the Health and Wellness Centre (HWC) facility.
The research team conducted structured observations of the HWC facility and  ows and
exchanges of students/ clients and providers and sta in the active work setting. Using the
POEMS framework (Kumar and Whitney, 2007 ) the research team captured references and
details for observations of ‘people, objects, environments, messages, and services’ in the clinic
and common campus areas. Observations included the HWC reception and waiting area, the
adjoining rooms, the building itself and its entry and egress points, and the use of space and
architectural features. Photographs and analysis contributed to contextual description of the
contribution of space to the health- seeking experience.
Small- sample interviews with four clinicians and sta and six students/ clients were held
within the clinic environment, to develop contextual understanding. The interviews were
oriented to the students’ experience of the HWC and services. Sta interviews asked about
mental health service and counselling processes and the unique nature of art and design
students.
Two group dialogue methods were employed for student/ client and public/ expert engage-
ment. With the service design lead, the HWC held a series of private student client dialogues
to learn the range of experiences and attitudes from counselling clients. The student group
dialogues were held as facilitated, open- ended focus groups and recorded by a team member
for later analysis. The public dialogue was an open, community- focused engagement convened
by the research team for students, faculty and professionals to explore the experience and
struggles of mental health and the enhancement of health services in a public dialogue. The
inquiry was focused around several key questions of interest:
Figure3.2 Mixed- method approach for action design research
Source :Jones,2015
9781472457424pt2_p33-382.indd 489781472457424pt2_p33-382.indd 48 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 49
49
• Are there innovations in community and social health that might enhance awareness and
improve mental wellbeing?
• How can we move beyond the conventional views of mental health and learn from
eachother?
• What might we understand together to cultivate empathy and insight about the experi-
ence of emotional and mental health journeys?
Rethinking service touchpoints and interaction
A service designer in the research team constructed a service blueprint of the counselling
work ow as a baseline process model (a core section of which is referenced in Figure3.3 ),
contributing to the learning and analysis.
Campus clinical mental health services were primarily for crisis management, and life man-
agement through counselling. The study found these services were provided too late in the
lifecycle of an individual’s developing wellness issue to support the capacity for  ourishing, in
the Keyes ( 2002 ) sense of self- acceptance and personal development. From a systemic perspec-
tive we identi ed the most productive (leveraged) opportunities for enabling and promoting
individual and social  ourishing.
The study further questioned the normative model of mental health service that has held
for at least two generations. The design research team developed early hypotheses (based on
observations of media use and communication) that the current generation of students may
express a di erent relationship to health services than in prior years, possibly a ecting service
design and supporting touchpoints.
Students face many, daily stressors and learn to face expected stressful situations with resil-
ience. The onset of most mental and emotional stress disorder symptoms and feelings are not
typically recognised as crises, requiring intervention, as the associated demands of student life
are expected. Emotional disorders may develop slowly, and can co- occur with exogenous
stressors (such as exams and critiques) that lend social proof to the experience of even signi -
cant stress, short of breakdowns, as ‘normal’ and expected. Gradual mental health languishing
(as Keyes refers to the state) does not occur to individuals as an acute, medical situation that
requires intervention.
As such concerns emerge in a student’s life, they must also cope with the multiple stressors
of a new environment, signi cant workload and school demands, and the attendant social
pressures, especially in coping with  rst- year social integration. Especially with college- age
males, the risk of an acute or urgent stress problem increases if supports in the local social
Tal k
Friends, staff,
relatives, faculty
Outreach
Events, fairs
Referral
HCP, staff,
faculty
Online
Website
Email
Social media
Phone
HELP
SEEKING
OCADU Health and Wellness Centre Flow
ARRIVAL TRIAGE COUNSELLING
SESSIONS
LEAVE OR
TRANSFER FOLLOW-UP
Walk-Ins
Crisis
Figure3.3 Basic work ow from HWC service blueprint
Source :Jones,2015
9781472457424pt2_p33-382.indd 499781472457424pt2_p33-382.indd 49 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

50 PeterJones
50
ecology of peers, work activities, positive relationships with faculty and school sta and other
‘unsought’ requirements are notmet.
In further analysis, the research team recognised that the service delivery of current mental
health o erings would bene t from some service improvements such as a simple client regis-
tration form, better online information and some changes in scheduling to bene t identi ed
student demand cycles. Aslate of service changes were de ned, including the major change of
providing walk- in counselling for crises wherever possible and covering the noon lunch hour
for student walk- ins and appointments.
Through comprehensive journey mapping of the full lifecycle of student experience,
from secondary school through university graduation, the design research team identi ed
and interpreted the signi cance of salient points of communication and awareness across
the lifecycle. Several intervention opportunities were identi ed for inclusions of salutogenic
enhancements (Antonovsky, 1996 ), such as peer engagement, campus health campaigns and
built environment enhancements. The well- de ned boundary of the university, its campus
and service infrastructure contribute to the design of communications and support services
for students in a non- client capacity. While such a context might not be recognised in the
same way for people not in a school or campus environment, living in urban or rural com-
munities, we suggest that other community contexts can learn from the design for  ourishing
in campus settings.
Soft service design can be seen as design for a health commons, providing supportive and
complementary resources within a social ecology for the emergence of bene ts for poten-
tially all participants in a social system. Providing soft services to promote  ourishing outside
the envelope of care, or in the case of HWC, ‘in advance of arrival’, was deemed to have a
signi cant contribution on students’ personal awareness of health and reduction of individu-
ated stress. The value to the HWC was seen as possibly signi cant over time, by reducing
the number of crisis visits and the level of stress attending their presentation, and by improv-
ing the knowledge and awareness of mental health overall and its contribution to individual
 ourishing.
Figure3.4 shows a graphical model of the soft service design for campus mental health devel-
oped from the design- action research. Three inferred stages of pre- arrival (peri- diagnostic)
encounter can precede the initial presentation at the HWC clinic, represented as Awareness,
Understanding and Connection. Each support stage addresses the escalation of concerns dis-
covered in ethnographic inquiry, shown in the coloured bars at the top of the diagram:
• lack of awareness (about mental health, concerns, with stigma, lack of knowledge);
• uncertainty (of one’s health status, of service should one seekhelp);
• isolation (the result of continuing to live with a growing or emerging concern in the
face of increased stressors).
The proposed pathway of individual learning and self- management is represented by the
arrows, indicating the potential to raise awareness and understanding, while reducing anxiety
and concern, through individual and peer interaction with supports and communicative
materials. We hypothesised that anxiety can be reduced su ciently to facilitate student
resilience and reduce crisis incidents that would lead to the mental health service encounter.
Further development of design contributions emerged from the research and soft service
proposals. Projects were de ned to help student health seekers better navigate the campus
service system and to enhance the accessibility of mental health services, three touchpoints of
which are notably soft services:
9781472457424pt2_p33-382.indd 509781472457424pt2_p33-382.indd 50 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 51
51
• Enhance communication processes to promote the resources that are available and better
articulate the role of mental health services and theHWC.
• Develop an online resource for the health seeker speci c to mental health including
FAQs, online tips and strategies and available resources.
• Formalise the broad range of support that is available (self- directed, peer- supported, email
counselling, group counselling, individual counselling and crisis support).
• Establish business processes that allow for some self- service (e.g. insurance opt- out pro-
cess, form requests and scheduling), better allocation of resources (e.g. use of volunteers)
and improved  ow (e.g. separate administrative roles from triage function).
A soft service design method for social ecologies
Soft services address the continuity of health- seeking experience by people in a community not
speci cally seeking care. The designation draws from the discovery of signi cant opportunities
for communication, peer engagement and community support within the critical time
preceding the need for service. In the campus mental health context, soft services might be
designed as ambient information and peer and community support practices made available
and accessible in advance of any service encounter, or between major episodes ofcare.
Soft services not only fall outside the envelope or boundary of professional encounters, they
are not even typically activities or activity systems, but background (but not backstage) services
accessible to anyone within a social context. Soft services provide layers of undesignated com-
munication, signi cations and way nding for support or further help. Combined with direct
Figure3.4 Soft service lifecycle in mental healthaccess
Source :Jones,2015
9781472457424pt2_p33-382.indd 519781472457424pt2_p33-382.indd 51 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

52 PeterJones
52
care services soft services provide continuous contexts, a ‘commons of care’ for continuous
availability of basic service, through supports and accessible communication.
A soft services model addresses interventions at pre- service stages of care access within a
social ecology:
• raising individual awareness;
• mitigating stigmas and reversing stigmas related to outdatednorms;
• providing accessible and on- demand information;
• enabling informal communications between service supports and potential bene ciaries;
• service way nding for all the stages of help;and
• feedback related to touchpoints, so that health seekers can identify their location within
a process.
Figure3.5 presents a design method referred to as the 4C journey map for formulating soft
service proposals (full lifecycle journeys and touchpoint de nition). This template has been
developed and evaluated in healthcare service design workshops, and has been instrumental in
designing new formulations for primary care and mental health service models. The four ‘C’
concepts are those that apply in any soft service application:Context, Constraints, Cues and
Figure3.5 4C journey– soft service design method template
Source :Jones,2015
9781472457424pt2_p33-382.indd 529781472457424pt2_p33-382.indd 52 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 53
53
Communications. ‘Care’ de nes the direct touchpoints and process of healthcare provision
and is speci c to healthcare. In another service context Care would be replaced by the direct
service functions of a di erent domain of provision.
The overall frame of the soft service design template represents a timeline of de ned and
opportunistic interactions accessible to participants in a socioecological system. The six guid-
ing constructs across the temporal journey represent the conditions created by an action
design team associated with stages or emergent movement over the journey. The novel value
identi ed in the application of the soft services model and template is discerned in discovering
the locations for a bene ciary or user to encounter relevant information, peers and other users,
and to learn from contexts in the environment, in advance of service.
The layered bands from Context to Journey are not designated in a relevant order or series
but are spatial placements, suggestive of the accessibility of designated signs and reference
touchpoints associated with the environment (Context) or the health seeker in a Journey
(series of steps that make progress toward a goal). The designer using this approach in a canoni-
cal way would organise the context and time frame initially, to identify known stages and time
markers along a continuum of typical service. The labels in the template suggest the various
indications of stages or milestones in an ecological soft service. We start with Context as fol-
lows, which might include stages of developmental experience as indicatedby:
• pre- concern;
• emergence or incident;
• help- seeking.
Context also includes  ve formal healthcare service stages, as conventional across many
applications:
• diagnoses;
• evolution;
• disposition;
• resolution;
• continuing.
The Journey stages, indicated at the bottom of the template, suggest the stages of experience
recognised within and outside of the service context. This band of the model represents the
experience of the health seeker, the expected and typical situations, their expectations and
feelings during the journey.
A service design model is indicated for the stages in the template (Aware, Join, Use, Develop,
Leave) based on Polaine etal. ( 2013 ). In most soft service applications these journey milestone
stages would be contingent, de ned for relevance to the health seeker rather than service
stages. The other bands are described brie y to suggest their use from applications.
Constraints represents the various sociomaterial process and physical entities that guide or
limit the degrees of progress or agency the health seeker may wish to express in the setting.
These include:
• channel constraints (i.e., internet, member of an organisation, bene ts group);
• wait lists and other operational constraints;
• physical locations and accessibility– the relative ease of access or constraints of location;
• payment and insurance, and other legal and  nancial constraints a ecting access to service.
9781472457424pt2_p33-382.indd 539781472457424pt2_p33-382.indd 53 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

54 PeterJones
54
Cues are context indicators to people in a service system, both providers (backstage) who
might be aware of and construct cues, and participants (frontstage) who might attend to cues
as ambient information at the point of need or awareness. Cues are represented ‘above’ the
line of Interaction, which represents the ‘service stage’ itself, where a participant encounters
service providers. Yet cues are here considered more indicators of context rather than direct
communication of meaning. These include signs and symbols relevant to the service ecology
(but perhaps foreign to a participant, such as in medical contexts), visible and provided
artefacts and situations, such as the cues for medication or a lab test, various spatial cues and
environmental markers, and ambient references such as magazines or print media, various
forms and tools of thetrade.
Care services directly provided to clients or health seekers can be situated between the line
of interaction (as interaction is direct) and the line of visibility (services and artefacts may not
be disclosed or visible to the patient). Direct health and care services are indicated within
the care as service band. The stages here show the series of touchpoints (care encounters),
treatments, examinations, clinical tests and other care team encounters, including physicians,
counsellors, pharmacists,etc.
The Communications band indicated de ned and designed communications to partici-
pants in the ecology, whether in care or pre- care (soft) service environments. We include
material forms and physician orders, voiced requests, prescriptions, information provided to
patients, caregiver conversations and peer- to- peer communications. As with any communica-
tion modes, media can include all forms of spoken, printed, online, image and mixed forms
(phone calls, forms, handouts, spoken orders, conversation).
Soft service theory and practice
The developing theory associated with the model describes the behaviours contributing to
individual, social and societal  ourishing, conceived of as interconnected relationships in a
socioecological system.
This foundation model of  ourishing in social systems was developed in prior work by
Upward and Jones ( 2016 ) and was in uential in the mental health study. We have extended
it to the social ecology of mental wellness in higher education campuses. We believe that the
model will have general applicability to public health promotion, preventive care and primary
care as these are multipurpose practices that provide resources for health e ects identi ed and
presented within their socially embedded environment.
There are distinctive di erences in design practice for soft service design. Asigni cant body
of service design research has been established from a constructivist approach (Meroni and
Sangiorgi, 2011 ). An interpretive epistemology is advanced, advocating ethnographic methods
for understanding service needs and interactions from the perspective of a participant’s expe-
rience. Yet in practice, most service design projects are performed following client- centred
practices derived from user experience methodologies. The tools of service design fall short
of motivating clients to expand the boundaries of service to peripheral, possibly uncontrolled,
supporting services in the service system.
A systemic design approach to soft services endorses reasonably similar steps and methods
in a design application situation to that of service design practice. Within the scope of a
given design process model (as critiqued in Jones, 2014 ) the steps in Table3.2 are recom-
mended to ensure that  eld research insights and design options support a soft service
approach.
9781472457424pt2_p33-382.indd 549781472457424pt2_p33-382.indd 54 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 55
55
Conclusion:designing for contexts of  ourishing
The reported research in this chapter describes a theory- supported and qualitative evidence-
oriented service design methodology in summary. Soft service design is derived from design
research and practice knowledge in a particular domain where the complementary service
model emerged as a predominant approach for improving accessibility and awareness of
conventional mental health services.
Developmental research on the methodology remains to be completed on the methodology
and its constituent methods, and design researchers are encouraged to work with the methods
and report at conferences or the literature. The reported methods and models (Flourishing
model, Soft Service Design, 4C Journey) have been used in various other contexts but only
reported in the mental health study, due to research protocols (our licence to report on the
study).
Numerous service design methodologies have been developed and o ered by global design
practices as tools for enabling service providers to develop competitive or high- value service
o erings with bene cial economic and social value. Service design perspectives been devel-
oped to recognise services across numerous con gurations:
• as product service systems (Manzini and Vezzoli, 2003 ; Tukker and Tischner 2006 );
• sociotechnical systems (e.g. in healthcare, Jones, 2013 );
• sociomaterial con gurations, as ‘designing for service’ (Kimbell, 2011 );
• transformation and transformative services (Sangiorgi, 2011 ).
This chapter advocates a contextualised and complementary approach to systemic service
design to enable  ourishing in community settings. While not arguing against public health
models of intervention in social determinants of health, the theoretical approach is based on
the social systems model of a social ecology that supports the same outcomes of health services,
but by addressing sources in the community setting and not (only) in the care practice setting.
A systemic approach developed as the soft service design model was informed by theories
of  ourishing in mental health and  ourishing societies from the ecological literature. An
integrated model oriented to this outcome has been adapted to identify and guide supports
for social interventions in collective health settings. We propose that this approach will be
found e ective in use by other organisations for intervening in the social systems surrounding
practices of care, outside the envelope of the healthcare system.
Table3.2 Endorsed steps toward soft servicedesign
1) Identify the scope and boundaries of service provision, to be de ned as the envelope of formal
service (both Context and Care in the template).
2) De ne the (formal service) value proposition and its canonical service  ow. Identify current
and expected new touchpoints (Care and Journey in the template).
3) Discover participants and locate them by role in the social ecology. Identify health seekers
(and patients), clinicians and sta providers, community stakeholders and other community
members.
4) Map the structures of anticipated needs and satisfactions, expected experiences and service
context across a full lifecycle (Care and Journey)
5) Discover and propose complementary resources as soft services across the range of journey and
context not ful lled by formal service (Context, Cues and Journey on the template).
9781472457424pt2_p33-382.indd 559781472457424pt2_p33-382.indd 55 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

56 PeterJones
56
References
American College Health Association ( 2013 ) National College Health Assessment II: Reference Group
Executive Summary Fall 2012 . Hanover, MD : American College Health Association .
Antonovsky , A. ( 1996 ) The salutogenic model as a theory to guide health promotion . Health Promotion
International , 11 ( 1 ): 11 – 18 .
Baetz , M. , Meng , X. , D’Arcy , C. and Muggli , T. ( 2015 ) High frequency users with mental health
complaints of emergency departments in a Canadian prairie city . European Psychiatry , 30 : 355 .
Bronfenbrenner , U. ( 1979 ) The Ecology of Human Development: Experiments by Nature and Design .
Cambridge, MA : Harvard UniversityPress .
Byrne , M. , Murphy , A.W. , Plunkett , P.K. , McGee , H.M. , Murray , A. and Bury , G.
( 2003 ) Frequent
attenders to an emergency department: Astudy of primary health care use, medical pro le, and
psychosocial characteristics . Annals of Emergency Medicine , 41 ( 3 ): 309 – 18 .
Capra , F. ( 1996 ) The Web of Life:ANew Scienti c Understanding of Living Systems . NewYork : Anchor .
Carey , G. and Crammond , B. ( 2015a ) Action on the social determinants of health:Views from inside the
policy process . Social Science and Medicine , 128 : 134 – 41 .
Carey , G. and Crammond , B. ( 2015b ) Systems change for the social determinants of health . BMC Public
Health , 15 ( 1 ): 662 .
Chisholm , D. , James , S. , Sekar , K. , Kumar , K.K. , Murthy , R.S. ,
Saeed , K. and Mubbashar , M. ( 2000 )
Integration of mental health care into primary care . British Journal of Psychiatry , 176 ( 6 ): 581 – 8 .
Christakis , A.N. and Bausch , K.C. ( 2006 ) How People Harness Their Collective Wisdom and Power to Construct
the Future in Co- Laboratories of Democracy . Greenwich, CT : Information Age Publishing .
Coburn , D. , Denny , K. , Mykhalovskiy , E. , McDonough , P. , Robertson , A. and Love , R. ( 2003 ) Population
health in Canada:Abrief critique . American Journal of Public Health , 93 ( 3 ): 392 – 6 .
Ehrenfeld , J.R. ( 2000 ) Colorless green ideas sleep furiously:Is the emergence of ‘sustainable’ practices
meaningful? Re ections , 1 ( 4 ):
34 – 47 .
Eisenberg , D. , Downs , M.F. , Golberstein , E. and Zivin , K. ( 2009 ) Stigma and help seeking for mental
health among college students . Medical Care Research and Review , 66 ( 5 ): 522 – 41 .
Ford , J.D. , Trestman , R.L. , Steinberg , K. , Tennen , H. and Allen , S. ( 2004 ) Prospective association of
anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency
medical care . Social Science and Medicine , 58 ( 11 ): 2145 – 8 .
Gloster , M. ( 2000 ) Approaching action research from a socioecological perspective . Systemic Practice and
Action Research , 13 ( 5 ): 665 – 82 .
Hepworth , J.
( 2015 ) Public health psychology:Aconceptual and practical framework . New Directions in
Health Psychology , 4 : 229 – 45 .
Jones , P.H. ( 2013 ) Design for Care:Innovating Healthcare Experience . Brooklyn, NY : RosenfeldMedia .
Jones , P. ( 2014 ) Design research methods in systemic design . Proceedings of RSD3 Relating Systems Thinking
to Design Symposium . Oslo : Oslo School of Architecture and Design .
Jones , P. ( 2015 ) Can we design for a  ourishing society? Proceedings of Relating Systems Thinking and
Design (RSD4) Symposium, Ban , Canada, September1– 3.
Jones , P. , Robinson , J. , Yip , A. , Oikonen , K. and Starkman , A. ( 2014 ) Human- centred mental wellness:
Discovering touchpoints before a service encounter . Touchpoint:Journal of Service Design , 6 ( 2 ): 58 – 61 .
Keyes ,
C.L. ( 1998 ) Social well- being . Social Psychology Quarterly : 121 – 40 .
Keyes , C.L. ( 2002 ) The mental health continuum:From languishing to  ourishing in life . Journal of
Health and Social Behavior : 207 – 22 .
Kimbell , L. ( 2011 ) Designing for service as one way of designing services . International Journal of Design ,
5 ( 2 ): 41 – 52 .
Kirby , M.J. and Keon , W. J . ( 2006 ) Out of the shadows at last:Transforming mental health, mental illness
and addiction services in Canada . Standing Committee on Social A airs, Science and Technology,
Senate of Canada.
Kumar , V. and Whitney , P. ( 2007 ) Daily life, not markets:Customer- centered design . Journal of Business
Strategy , 28 ( 4 ): 46 – 58 .
9781472457424pt2_p33-382.indd 569781472457424pt2_p33-382.indd 56 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM

Soft service design around healthcare 57
57
Levin , S.A. ( 1998 ) Ecosystems and the biosphere as complex adaptive systems . Ecosystems , 1 ( 5 ): 431 – 6 .
Luhmann , N. ( 1997 ) Globalization or world society:How to conceive of modern society? International
Review of Sociology , 7 ( 1 ): 67 – 79 .
Manzini , E. and Vezzoli , C. ( 2003 ) A strategic design approach to develop sustainable product service
systems:Examples taken from the ‘environmentally friendly innovation’ Italian prize . Journal of Cleaner
Production , 11 ( 8 ): 851 – 7 .
Marmot , M. , Friel , S. , Bell , R. , Houweling , T.A. , Taylor , S. and Commission on Social Determinants
of Health ( 2008 ) Closing the gap in a generation: Health equity through action on the social
determinants of health . Lancet , 372 ( 9650 ):
1661 – 9 .
Meroni , A. and Sangiorgi , D. ( 2011 ) A new discipline . Design for Services : 9 – 33 .
Miller , J.G. ( 1972 ) Living systems:The organization . Behavioral Science , 17 ( 1 ): 1 – 182 .
Plsek , P. ( 2001 ) Appendix B: Redesigning health care with insights from the science of complex
adaptive systems , in IOM Committee on Quality of Health Care in America , Crossing the Quality
Chasm:ANew Health Care System for the 21st Century . NewYork : Institute of Medicine , 322 – 35 .
Polaine , A. , Løvlie , L. and Reason , B. ( 2013 ) Service Design:From Implementation to Practice . Brooklyn,
NY : RosenfeldMedia .
Popovic , T. ( 2012 ) Mental Health in Ontario’s Post- Secondary Education System . Toronto : College Student
Alliance .
Raphael , D. ( 2009 ) Social Determinants of Health:Canadian Perspectives . Toronto : Canadian Scholars’
Press .
Sangiorgi , D. ( 2011 ) Transformative services and transformation design . International Journal of Design ,
5 ( 2 ): 29 – 40 .
Swann , C. ( 2002 ) Action research and the practice of design . Design Issues , 18 ( 1 ): 49 – 61 .
Tukker , A. and Tischner , U. ( 2006 ) Product- services as a research  eld:Past, present and future. Re ections
from a decade of research . Journal of Cleaner Production , 14 ( 17 ): 1552 – 6 .
Upward , A. and Jones , P. ( 2016
) An ontology for strongly sustainable business models: De ning an
enterprise framework compatible with natural and social science . Organization and Environment ,
29 ( 1 ): 97 – 123 .
World Health Organization ( 2010 ) International Classi cation of Diseases Revision 10 (ICD10).
International Statistical Classi cation of Diseases and Related Health Problems . Geneva : World
Health Organization .
9781472457424pt2_p33-382.indd 579781472457424pt2_p33-382.indd 57 1/20/2017 12:47:05 PM1/20/2017 12:47:05 PM