Merging theory and practice in service design

Part 2: The recursive relationship between the context and the service

Welcome back to our 7-part series. In part 2, we explore how the context or ecosystem in which a service exists influences and is influenced by the service – its design, implementation, use, and evaluation. Understanding this dynamic relationship is essential for creating services that are adaptable, resilient, user-centric, context- and impact-aware. We’ll be guided by two key theories and a framework: Actor Network Theory (ANT), Structuration Theory (ST), and the Structure, Process, and Outcome framework.

We’ll explain each theory, introduce its key concepts, and explore practical applications for service design.

Before we delve into the details however, there are two important points to bear in mind:

1. Theory adaptation for service design: the theories we are discussing were not initially developed with a focus on services. For example, Structuration Theory (ST) provides valuable insights into social structures without explicitly mentioning technology. I have adapted these theories to connect their focus on technology and social dynamics with products and services. This approach allows us to apply their concepts to service design, ensuring their relevance while maintaining the original essence. This adaptation also lets us use the term “ecosystem” interchangeably with various adaptations of term “context” used within these theories like “network” and “social systems” used within these theories.
2. Consistent example – Telehealth: throughout this series, we will use telehealth as a service example to illustrate key points and concepts. Telehealth refers to the delivery of healthcare services through digital communication technologies, allowing for remote consultations, diagnosis, and treatment. It is a complex service that operates within a highly intricate context, intersecting with technology, user interaction, and regulatory requirements. Telehealth provides a rich case study for demonstrating the practical applications of these theories. The processes involved in telehealth – from ensuring data privacy and compliance with health regulations to integrating seamlessly into patients’ and providers’ routines – highlight the challenges and opportunities in service design.

With these points noted, let’s start our journey by examining how the Actor Network Theory (ANT) provides a network-centric viewpoint essential for understanding the dynamics within service ecosystems.

The context and service relationship.

1. Navigating networks and negotiations: Actor Network Theory

Actor Network Theory (ANT), developed by Callon, Law, and Latour, provides a network-centric viewpoint that is essential for understanding the dynamics within service ecosystems. ANT offers insights into the connectivity of the network (i.e., ecosystem) and the symmetry between its actors (i.e., users and technology). It invites us to consider that each actor has the inherent ability to change, influence, and transform the network or itself. ANT recognises that all actors are constantly negotiating for balance when interacting with each other within the network, and contributing towards achieving shared goals.

1.1 Key Concepts and applicability in service design

Let’s explore the 4 main ANT concepts relevant to service designers. For each concept, we will identify what it is, why it is important, and how it can be practically applied.

1.1.1 Network-centric view of an ever-evolving network

What: ANT emphasises the importance of understanding the entire network of actors (both human and non-human) and their interactions. It highlights that every actor within the network influences and transforms the network (ecosystem).

Why: this perspective helps service designers recognise that a service does not operate in isolation. Services exist in ever-changing and adapting contextual settings. Appreciating the complex interactions within an evolving ecosystem helps in designing services that are adaptable and responsive to changes in timely manner.

How: by examining where the service is positioned within its complex and evolving context (network) – its current role and offerings, as well as potential extensions – service designers can better understand its dynamics. This analysis can be visually captured through ecosystem maps and service blueprints that highlight actor’s actions, connections, journeys, dependencies, gaps, touchpoints, pain points, and opportunities.

For example, during the COVID-19 pandemic, many telehealth based services were used to address the immediate need for care delivery - expanding its capabilities to ensure patients could access healthcare services without visiting clinics in person. The approach addressed both user needs and business objectives, maintaining continuity of care while adhering to public health guidelines.

1.1.2 Symmetry of agency

What: ANT posits that all actors, whether human (e.g., patients, healthcare providers) or non-human (e.g., telehealth devices, policies), have equal influence within the network (ecosystem).

Why: recognising the symmetry of agency ensures that service designers consider the impact of every actor equally, leading to more balanced and inclusive service design.

How: by mapping interdependencies between different actors across the ecosystem, service designers can highlight actors with larger dependencies on others and those on whom other actors are reliant. This helps understand the potential consequences if an actor does not act as intended or ceases to exist, thereby mitigating risks by identifying and mapping risk factors.

For instance, in a telehealth ecosystem, the electronic health record (EHR) system is a critical actor. If the EHR system fails, it could lead to severe consequences for both patients and clinicians. Patients might face delays in receiving care, incorrect treatment due to lack of access to medical history, or breaches of privacy if data is compromised. Clinicians, on the other hand, might struggle with incomplete patient information, increased workload to manually retrieve or record data, and potential legal implications due to errors in patient care. Understanding these dependencies allows service designers to develop contingency plans, such as backup systems, robust data recovery processes, and alternative communication channels, to ensure continuity and reliability of the service.

1.1.3 Negotiation and power dynamics

What: ANT highlights that continuous negotiations among actors shape the network. These negotiations occur due to power dynamics and how different actors perceive changes.

Why: by understanding the power and vested interests of different stakeholders, service designers can navigate and manage tricky relationships, leading and facilitating negotiations to ensure successful service design, implementation, and use.

How: by mapping stakeholders according to their power and interest, service designers can develop a stakeholder engagement plan that ensures stakeholders are provided with relevant information and invited to collaborate based on their level of interest in the service.

For example, addressing the concerns of powerful stakeholders, such as GPs in primary healthcare who act as gatekeepers, is crucial. GPs have high power and high interest in telehealth offerings due to its care delivery model and the associated financial implications. To keep them closely involved, the engagement plan might include demonstrating the benefits of telehealth to alleviate job security concerns, regularly communicating with them, and adjusting the service based on their feedback. Additionally, showing the financial benefits and incentives of adopting telehealth can help secure their support and participation.

1.1.4 Sociology of translation in practice

What: sociology of translation involves aligning the interests of various actors to successfully integrate the service into practice.

Why: this process ensures that all stakeholders (actors) are committed to the service’s success.

How: co-design workshops with patients, healthcare providers, and policymakers can help align goals and create a shared vision for the service, facilitating smoother implementation and greater use. In the context of telehealth, this might involve tailoring the service to fit within existing healthcare practices.

For example, telehealth services can be designed to integrate seamlessly across different organisations, such as GP surgeries within primary care, hospitals within secondary care, and residential homes within tertiary care. This approach ensures that telehealth services comply with relevant regulatory policies and frameworks, enhancing coordination and continuity of care across the healthcare system. By involving all stakeholders in the design process, telehealth services can be more effectively tailored to meet the needs and expectations of each group.

While ANT provides a detailed view of how actors interact and negotiate within a connected network, we will also benefit from understanding how these negotiations and interactions shape social norms and rules, thereby embedding the use of services such as telehealth. This leads us to Structuration Theory, which we will discuss next.

2. Enacting structures within a social system: Structuration Theory

Structuration Theory (ST), developed by Anthony Giddens, posits that within any social system (context), structures (rules and tools) are enacted through human action (users). These structures emerge from interactions of human agency (users’ knowledge and capabilities) within the bounds of their social system.

ST encourages us to recognise that how a service is used and interacted with in a given context is a socially driven action. This action stems from observing what other agents (users) are doing and from one’s own agency. It results in various engagement rules being enacted around that service due to user expectations, past experiences, and efforts to establish normality around newness.

2.1 Key concepts and applicability in service design

Let’s discuss the 3 concepts from ST that are relevant to service design. For each concept, we’ll explain what it is, why it matters, and how it can be practically applied.

2.1.1 Understanding mutual influence — designing for social systems and the long-term impact

What: ST posits that services and their contexts influence each other reciprocally. This means that the interaction between users and the services they use shapes the service and modifies the broader context in which the service exists. Users’ actions, influenced by their experiences and social norms, contribute to the creation and modification of social structures. These structures (which include the services), are continuously evolving as users engage with and adapt them to meet their needs within a given context.

Why: recognising this mutual influence helps service designers create services that are contextually relevant, responsive to users’ needs, and impact-aware. It ensures that even small changes are considered for their wider implications. In addition, this ensures acceptance and engagement by making the service feel familiar, trustworthy, and respectful to users’ beliefs.

How: by factoring in mutual reciprocity and impact, service designers can capture interdependencies between various service stages and contextual elements. They can conduct thorough contextual inquiries to design services that align with local cultural and social practices. Consider an example of a telehealth service in a culturally rich rural area.

In such a context, it is important to understand the local culture and how traditional practices influence healthcare decisions. Suppose the local population relies heavily on traditional healers and herbal remedies. A telehealth service could be designed to include consultations with traditional healers alongside modern medical practitioners. This dual approach could involve traditional healers using the platform to provide advice and treatments that align with cultural practices while collaborating with doctors to ensure that patients receive comprehensive care.

To gain trust, the telehealth service might also offer educational sessions that explain how the service works and how it respects and integrates traditional healing methods. Additionally, telehealth providers could host community meetings to gather feedback and address any concerns, showing respect for local customs and involving the community in the development process.

This approach ensure long-term acceptance and integration of telehealth into the community’s healthcare ecosystem, and service’s relevance and effectiveness to the evolving cultural and healthcare needs.

2.1.2 Incorporating flexibility in structures

What: ST suggests that the structures (including services) users interact with can be both enabling and constraining. Ingraining flexibility allows users to adapt services to their needs.

Why: by perceiving service as a structure that may be enabling and constraining, service designers can build flexibility into a service to accommodate diverse user needs within a given context.

How: this might involve creating modular service components that can be customised based on user feedback and changing needs. For example, telehealth platforms that are adaptable to different user capabilities and healthcare requirements allow for personalised user experiences.

Let’s consider a telehealth platform that could offer various modules tailored to different user capabilities and healthcare requirements. One module could provide basic video consultation services for patients with limited technological skills, featuring an intuitive, easy-to-navigate interface. Another module could offer advanced features like integration with wearable health devices for more tech-savvy users who require continuous monitoring of chronic conditions.

Additionally, the platform could include customisable features such as language options, accessibility tools for patients with disabilities, and specialised modules for different healthcare needs (e.g., mental health, chronic disease management).

This flexibility allows the service to adapt, maintaining its relevance and user satisfaction over time.

2.1.3 Technological frames

What: technological frames refer to users’ pre-existing beliefs and assumptions about technology, which influence how they engage with it. These frames may also include experiences from unintended uses, where some (or all) of a service’ s components were used in ways not initially intended by the designers.

Why: being aware of these frames helps service designers address potential biases and misconceptions. Additionally, anticipating unintended uses helps in creating more resilient services.

How: service designers can incorporate educational elements and clear communication strategies to build trust and demystify the technology, while also designing flexible and inclusive service components that accommodate a range of user behaviours and ensure robust security measures.

Consider a telehealth platform designed by a healthcare company that recently experienced a data breach and was held at ransom. Both the business and users now have heightened concerns about privacy and security, leading to distrust in digital health solutions. To address this, service designers in this case, could develop a comprehensive educational campaign explaining the new, enhanced security measures implemented to protect user data. This campaign could include interactive online workshops, informative videos, and detailed FAQs.

Additionally, the platform could be designed with user-friendly interfaces featuring strong security cues (e.g., visible encryption icons, two-factor authentication) to reassure users. Features that allow users to control their data, such as opting out of data sharing or accessing personal data logs, would enhance trust.

To accommodate unintended uses while ensuring security, the platform might include robust security measures such as secure databases, regular security audits, and fail-safe mechanisms to prevent and mitigate potential misuse.

Understanding how services and contexts mutually shape each other through user interactions is vital for creating relevant and adaptive services. By recognising these interactions and the flexibility required to accommodate diverse needs, service designers can build more effective and responsive solutions. However, ensuring the quality and effectiveness of these services also requires a structured approach to assessment. This brings us to the Structure, Process, and Outcome framework, which provides a systematic method for evaluating service performance.

3. On quality assessment: Structure, Process, and Outcome Framework

Lastly, let’s look at the Structure, Process, and Outcome framework proposed by Donabedian. This framework is used to assess the performance of healthcare services and evaluate their impact on the quality of care.

Note that definition of structure in this framework is different to what structure means in ST.

3.1 Key concepts and applicability in service design

By applying this framework, service designers can build evaluation mechanisms to ensure robust, user-centred quality services. We’ll explore 3 key concepts.

3.1.1 Structure: the setup of a service within its context

What: in Donabedian’s framework, ‘structure’ refers to the physical and organisational infrastructure needed to deliver a service. This includes facilities, equipment, staff qualifications, and organisational characteristics.

Why: understanding the structure helps service designers ensure that the foundational elements are in place for effective service delivery.

How: by evaluating the existing infrastructure and identifying gaps that need to be addressed, service designers can ensure the foundational elements are in place for effective service delivery.

For instance, implementing telehealth services in rural areas involves several critical steps:

First, service designers must assess the availability and reliability of internet infrastructure. In many rural areas, internet connectivity may be limited or unstable.

Next, appropriate medical devices need to be identified and distributed to patients. This could include devices like blood pressure monitors, glucose meters, and wearable health trackers that can transmit data to healthcare providers remotely. Ensuring that these devices are user-friendly and compatible with the telehealth platform is crucial.

Additionally, training healthcare professionals to operate and support the telehealth system is essential. This includes technical training on how to use the telehealth software and equipment, and training on how to provide effective patient care remotely.

Finally, service designers must establish protocols and workflows that integrate telehealth services into the existing healthcare system. This might involve creating guidelines for scheduling virtual appointments, managing electronic health records, and ensuring data privacy and security.

3.1.2 Process: actions taken to deliver the service

What: ‘Process’ refers to the methods and procedures used to deliver the service. This includes all interactions between patients and healthcare providers, the workflows, and the clinical protocols followed.

Why: understanding the processes involved in service delivery helps designers create efficient and user-friendly workflows.

How: by creating process maps that outline each step of the telehealth service delivery, designers can ensure the service is efficient and user-centric.

For example, the process of delivering telehealth services can be broken down into several key steps.

1. Initial contact: the first step involves patients accessing the telehealth service, which could be through a dedicated app, website, or a phone call.
2. Appointment scheduling: next, the process of scheduling appointments could involve an online booking system where patients can select available time slots that fit their schedule.
3. Consultation: may include how the virtual meeting is conducted, how patient information is accessed and shared, and how the consultation is documented.
4. Follow-up actions: may include sending prescriptions to pharmacies, scheduling follow-up appointments, and monitoring patient progress.

By analysing each step through process maps, service designers can identify potential bottlenecks and areas for improvement. For example, if many patients miss their scheduled appointments, the process map might reveal that reminder notifications are sent too late. Adjusting this step to send reminders earlier could improve attendance rates.

Additionally, incorporating user feedback at each stage is crucial. Regular surveys or feedback forms after each interaction can provide valuable insights into what is working well and what needs improvement. This continuous refinement process ensures that the telehealth service remains efficient, user-friendly, and responsive to patient needs.

3.1.3 Outcome: results of the service

What: ‘Outcome’ refers to the results of the service delivery, including patient health outcomes, satisfaction levels, and other relevant metrics that indicate the effectiveness of the service.

Why: evaluating outcomes ensures that the service meets its intended goals and delivers value to users. In addition, it helps service designers make data-driven decisions to enhance the service’s effectiveness over time, ensuring it remains aligned with those goals and values.

How: by establishing clear metrics to evaluate the outcomes of telehealth services and aligning service aims with organisational goals using Key Performance Indicators (KPIs) to track success and identify areas for improvement.

For example, a telehealth service designed to manage chronic heart failure might establish several key metrics to evaluate its effectiveness:

1. Health metrics: these could include specific health outcomes such as a reduction in hospital readmissions for patients with chronic heart failure. Tracking the number of hospital readmissions before and after implementing the telehealth service can provide a clear indicator of its impact on patient health.
2. Usage statistics: analysing usage statistics can provide insights into how often and in what ways the service is being used. Metrics could include the number of virtual consultations conducted, average consultation time, and patient engagement levels. This data can highlight patterns and areas where the service might need adjustments.
3. Clinical outcomes: evaluating clinical outcomes such as adherence to medication, management of symptoms, and overall health improvement can indicate the effectiveness of the telehealth interventions.

Aligning these metrics with the organisation’s goals ensures that the telehealth service delivers on its promises. For example, if one of the organisational goals is to improve access to healthcare in remote areas, tracking the increase in the number of patients from these areas who use the telehealth service would be relevant.

In addition, regularly reviewing these metrics allows for continuous monitoring and evaluation, leading to iterative improvements. For example, if health metrics show that readmission rates are not decreasing as expected, it might prompt a review of the care protocols and interventions provided through the telehealth service.

Conclusion

In Part 2, we examined the intricate dynamics between context and service, using theoretical perspectives to provide insights into this relationship. By integrating concepts from Actor Network Theory (ANT), Structuration Theory (ST), and the Structure, Process, and Outcome framework, we highlighted the multifaceted nature of service design within complex ecosystems.

ANT provides a comprehensive view of the ecosystem, emphasising that all elements within the network — human and non-human — interact and influence each other continuously. This perspective encourages service designers to acknowledge and capture these interdependencies, highlighting areas of contention and opportunity. Understanding that the network is constantly evolving also ensures that services remain adaptable and resilient to change.

ST emphasises that services and their contexts mutually shape each other through the actions of human agents. By considering how users enact and modify structures within their social systems, service designers can create more relevant and adaptive services. This approach ensures that services align with existing social norms and practices, facilitating smoother adoption and integration.

The Structure, Process, and Outcome framework guides service designers in assessing the quality and effectiveness of their services. By focusing on the structure (setup), process (actions), and outcome (results), designers can build in mechanisms for continuous evaluation and improvement. This ensures that services are effective in meeting user needs, business needs (KPIs), are resilient and sustainable in the long term.

However, despite being rich in their offerings, it is essential to recognise that each theory comes with its own set of limitations. Understanding these helps in applying the theoretical concepts in a complementary and holistic way than standalone. Some of the relevant drawbacks and considerations include:

• ANT’s symmetry of agency: The concept of equal agency among human and non-human actants can be contentious. User-centred design practitioners might argue that equating the agency of humans with machines undermines the human experience and reduces the importance of user needs and behaviours.
• ANT’s underlying assumption that all actors within a network are negotiating and working towards shared goals: this assumption can be problematic when certain actors, often labelled as “bad actors,” are not aligned with the collective objectives or, worse, are actively working to disrupt the balance. These actors may refuse to negotiate or cooperate, thereby creating imbalances and conflicts within the network. For example, in a telehealth ecosystem, while most stakeholders may aim to improve patient outcomes and streamline healthcare delivery, a bad actor (such as a technology provider prioritising profit over patient privacy) could undermine these efforts. This misalignment can lead to failures in service delivery, mistrust among stakeholders, and ultimately, the collapse of the intended network harmony. Recognising and addressing the presence and influence of such actors is crucial for maintaining a resilient and effective service ecosystem.
• ST’s cultural sensitivity: while ST emphasises cultural and social norms, failing to deeply understand these aspects can lead to designs that appear culturally sensitive on the surface but miss critical nuances. Conversely, services may be shunned by users who find cultural or religious contextualisation offensive.
• Structure, Process, and Outcome framework’s focus on outcomes: This framework can sometimes be seen as rigid, focusing heavily on measurable outcomes related to care. While useful, it might not be fully adaptable to contexts like banking, where values such as equity may be contradictory to the profit-oriented ethos of the context.

Together, by integrating these theoretical perspectives and acknowledging their potential drawbacks, service designers can create context- and impact-aware services that resonate deeply with their stakeholders and users, while also being mindful of potential risks and ways of mitigating them.

Next, in part 3, we’ll explore the relationship between services and users, furthering our understanding of how to create context- and impact-aware user-centric services. Stay tuned!

Reference list

Actor Network Theory

1. Latour, B. (1999). On recalling ANT. In: J. Law and J. Hassard (Eds.), Actor Network Theory and after (pp. 15–25). Blackwell Publishing.
2. Law, J., & Callon, M. (1992). The Life and Death of an Aircraft: A Network Analysis of Technical Change. In: W. Bijker and J. Law (Eds.), Shaping technology/building society: studies in sociotechnical change (pp. 21–52). MIT Press.

Structuration Theory

1. Giddens, A. (1984). The Constitution of Society: Outline of the Theory of Structuration. Polity Press.

Structure, Process, and Outcome Framework

1. Donabedian, A. (2003). An Introduction to Quality Assurance in Health Care. Oxford University Press.