• Non ci sono risultati.

Adapting design tools to incentivize the development of design capability in healthcare. A case study

N/A
N/A
Protected

Academic year: 2021

Condividi "Adapting design tools to incentivize the development of design capability in healthcare. A case study"

Copied!
144
0
0

Testo completo

(1)

Adapting design tools

to incentivize

the development of

design capability

(2)

Adapting design tools

to incentivize the development of

design capability in healthcare

a case study

in cooperation with

Master Thesis

School of Design

Product Service System Design

Supervisor: Daniela Sangiorgi

Felicitas Schmittinger

Matricola: 880113

(3)

Healthcare is profoundly changing in its way to communicate, provide and carry out care processes. The ageing population and the change of society from a product-oriented into a service- and experience-oriented society requires a new way to innovate healthcare.

Service design is a potential response to this need and this thesis aims to explore how design tools, methods, and techniques can be modified to build design capability among the members of an organization in a healthcare context.

An initial research has been carried out to understand the potential of design tools, specifically the customer journey, at Centro Medico Santagostino where the research took place.

In the following, an action research project was conducted to explore how design tools, specifically the customer journey, could be modified to enhance the building of design capability.

The customer journey as a tool has been adapted to break barriers to service design and empower organizational members in building design capability with little training.

Keywords: design capability, knowledge transfer, design tools, action research, healthcare, customer journey

(4)

At first, I’d like to thank my supervisor, Daniela Sangiorgi, for her support and efforts throughout the whole process. Backing up with expert knowledge and being available for feedback and questions helped me during this 6 months.

A big thank you to Daniela Petrillo who motivated me to go for this thesis and fully supported me during the development. I could not have wished for a better tutor!

Thank you to Centro Medico Santagostino and the best department: Greg, Virginia and Marco, thank you for your feedback, your time, your patience and your support!

Thank you to all the others for the participation in my research and the countless lunch- and coffee breaks spent together.

Thank you, Vanessa, for helping me through the jungle of literature, being by desk companion and making my coffee breaks this summer. Thank you to everyone I had the chance to meet in these two years of PSSD, I could not have made a better choice for a masters

Thank you to my family: Mama, Papa, Leo, Luki, danke fuer eure Unterstuetzung in jeder Situation, die Telefonate und aufbauenden Nachrichten in den stressigsten Zeiten!

Thank you to all my friends, that pulled me away from my desk at least for some hours for a beer when it was most needed.

Palestra Vela, you all have no idea how many of my days you saved and made me return to my desk a little less exhausted than before.

Fede, thank you for all your support and help, not just during this thesis, but in these two years in Italy. Your positivity, feedback, our talks and jokes have supported me beyond explanations. Thank you!

(5)

Table of contents

Abstract

Acknowledgement

Table of contents

1. Introduction

I. Setting and Context

2. Background

2.1 Service Design

2.1.1 Definition

2.1.2 Brief history

2.1.3 Key elements

2.1.4 The service design process

2.1.4.1 Sequence and phases

2.1.4.2 Characteristics of the single phases

2.1.5 Tools and methods

7

9

11

19

23

25

27

27

27

29

33

33

36

38

(6)

2.1.5.2 Ideation

2.1.5.3 Testing

2.1.6 The perception of service design

2.1.6.1 Variety of fields including the term design

2.1.6.2 Long and short term implication

2.2 Health and Healthcare

2.2.1 Trends and tendencies in healthcare

2.3 Service Design in healthcare

2.3.1 Design in healthcare

2.3.2 Service design in healthcare

2.4 The issue of design capability

3. Context of research -

Centro Medico Santagostino

3.1 State of the art - healthcare in Italy

3.1.1 Public vs private

3.2 Centro Medico Santagostino

3.2.1 Size, growth, and numbers

3.2.2 Tone of voice and organizational culture

3.2.3 Departments and system

3.2.4 Service design in the research context

II. Research

4. Aim and methodology of research

4.1 Aim

4.2 A tailored research practice for CMS -

a methodology for the customer journey

4.2.1 First phase - cycle of research

4.2.1.1 Shadowing

4.2.1.2 Data extraction

4.2.1.3 Semi-structured interviews

4.2.1.4 Results

4.2.2 The customer journey as a tool

4.2.3 The customer journey as a guide -

from digital to analogue

4. 3 Spreading design -

The need for a theoretical framework

4.4 Designing out of the design department -

Action research

4.4.1 Characteristics of action research

4.4.2 Motivation for an action research project

in this specific case

4.4.3 Criteria for the choice of the context

4.4.4 Structure of the action research project

40

41

43

43

44

49

51

55

55

59

65

73

75

77

83

85

87

91

93

97

101

105

107

107

107

109

113

115

117

119

121

123

123

127

128

129

(7)

4.4.6 Preliminary interviews and questionnaire

4.4.7 Consecutive interviews and questionnaire

5. The customer journey

5.1 Mapping user flows with the customer journey

5.1.1 The customer journey as a tool

5.1.2 Customer journeys not just for designers

5.1.2.1 Designers Italia

5.1.2.2 Smaply

5.1.3 Customer journeys in healthcare

5.1.3.1 Karolinska University Hospital -

A new operating model

5.1.3.2 Clìnica Las Condes -

Healthcare customer journey mapping

5.1.3.3 Experio Lab - The patient journey

5.1.3.4 Reflections

5.1.4 Motivation for a concentration on the customer journey

5.1.5. Need for the use of the customer journey at CMS

6.1 First cycle

6.1.1 Initiating the research for the customer journey

6.1.2 The CJ to visualize and detect weaknesses

6.1.3 Findings after the first cycle

6.2 Second cycle

6.2.1 Proceedings of the customer journey

6.2.2 The CJ as a versatile tool

6.2.3 Findings after the second cycle

6.3 Third cycle

6.3.1 Finalization of the customer journey

6.3.2 The CJ as a guideline

6.4 Reflections and findings

7. Building design capability

7.1 Definitions of design capability

7.1.1 Design capacity and design capability

7.2 The process of building design capability

7.3 Absorptive capacity

7.3.1 Preconditions for the absorption of knowledge

7.3.2 Interferences of old and new knowledge

7.4 Theoretical framework

135

139

141

143

143

145

147

149

151

153

157

159

160

161

163

173

173

175

177

179

181

183

183

185

185

189

191

195

199

201

203

205

205

209

211

(8)

8. The action research project

8.1 Project context -

Introduction of the sales of hearing aids at CMS

8.1.1 Motivation for the project

8.2 Preliminary activities

8.2.1 The perception of service design - General position

8.2.2 The importance of customer experiences -

Importance of the user

8.2.3 Ways of working and planning - Preconditions

8.2.4 Considerations for the action research

8.3 The action research

8.3.1 First cycle - framing potential user journeys

8.3.1.1 First cycle - findings

8.3.2 Second cycle - drafting on paper

8.3.2.1 Second cycle - findings

8.3.3 Third cycle - sharing and engaging digitally

8.3.3.1 Third cycle - findings

8.3.4 Fourth cycle - getting things together in a workshop

8.3.4.1 Fourth cycle - findings

8.4 Consecutive phase

215

219

219

221

221

223

225

227

229

229

230

231

233

235

237

239

243

245

III. Results and Conclusions

9. Results and reflections

9.1 Relation to the theoretical framework

9.2 Empirical analysis

9.3 Conclusions

9.3.1 Limitations of the study

9.3.2 Potential future development

References

Bibliography

List of figures

List of tables

251

253

257

261

263

264

265

267

269

279

287

(9)

Customer experiences in healthcare are specifically delicate and unique and the growing trends towards digital and multichannel experiences are changing the way of how a patient-centred approach is applied to improve the patient experience.

The interrelation of digital and human touchpoints and the delicacy of the service itself make an analysis of perceptions even more difficult, every development requires a complex consideration process.

Service design provides a set of tools, among which the customer journey map, to draw patient pathways, ideate uncommon solutions and test project outcomes while taking all the influencing factors and touchpoints in consideration.

At the same time, the discipline of service design itself underwent significant changes in the past 30 years, changing the way service designers work and their role in organizations.

Being more focussed on the internal part of organizations, its members and company culture, the single members of an organization and their background becomes more and more important.

There is a notable trend in adopting service design in organizations of all scales not just to improve their efficiency, implement new services and improve existing ones, but also to provide a new set of skills and a different way of thinking to their employees.

Integrating service design and its different, new approach into

organizations with solid patterns and methods of working can cause problems of adaptation and integration.

This transformation and adoption process depends a lot on the structure and the way how an organization is led, the background and interest of the single members, but also a lot on the approach of the service designers themselves.

(10)

Even the culture of the country where the organization is located plays a role in how service design is viewed and eventually known, recognized and, therefore, in the next step, eventually absorbed.

Having to face that many variables, there is no “one size fits all”-solution on how to implement service design in organizations.

This thesis aims to further explore the integration of service design methods into a young and innovative organization in the private healthcare sector in Italy. After six months of being inserted as a service design intern in various projects at Centro Medico Santagostino, the division of service design and the rest of the organization triggered some reflections and assumptions have been made. During this period, a tailored research methodology has been developed to depict the entire patient journey in a customer journey map.

To actively introduce service design in the organization, a literature review on building design capability and knowledge transfer resulted in a theoretical framework to follow during an action research project. Based on all the previous research, its outcomes and feedback, the action research project has been conducted to obtain a view on the state of the art of service design in the company, the design capability of its members and how it could potentially be developed further using design tools as support. One utensil in specific, the customer journey, which is one of the most important ones in service design and has been the base for the action research, has been utilized to conduct the investigation and to reflect on the ways of use.

The action research found a general openness and interest towards service design, but also identified the need not just to elaborately in-troduce design tools for everyone s’ use, but also adapt them to break barriers and make the use more intuitive.

« Because organizations now operate in an

environment of constant change, the challenge

is not how to design a response to a current

issue, but how to design a means of continually

responding, adapting and innovating.

Transformation design seeks to leave behind

not only the shape of a new solution, but the

tools, skills, and organizational capacity for

ongoing change. »

— Burns et al., 2006

[1] [1] Burns, C., Cottam, H., Vanstone, C., & Winhall, J. (2006). RED paper 02:

(11)

SETTING AND

CONTEXT

I.

(12)

BACKGROUND BACKGROUND

Chapter 2

Background

About service design,

healthcare, and design capability

27

Service Design

Definition

Brief history

Key principles

The service design process

Tools and methods

The perception of service design

Health and Healthcare

Trends and tendencies in healthcare

Service Design in healthcare

Design in healthcare

Service design in healthcare

The issue of design capability

49

55

(13)

The exact definitions on what service design exactly consists of and what exactly its field of work is, vary remarkably in literature

(Stickdorn, 2011; Junginger, 2009).

This is not just because of the general difficulty to define the borders of service design, but also because it is constantly evolving as a field, that sets new focusses due to societal and organizational changes since the 1980s. In the last years, there have been various publications trying to synthesize not just the evolution of service design, but also its specific methods and practitioners. Stickdorn et al. drew a history of service design, the relation of this development to the changing society and articulating specific aspects and methods (Stickdorn et al., 2011). Speaking generally, service design aims to develop new or reform existing processes to improve the final service delivered to the user. It is applied to plan services from the beginning as well as to enhance already active services.

Service design was born as a discipline to build lasting customer relationships, mainly in the field of product sales. With the change of society from an industrial and consumption-based towards an

experienced-based service economy, companies started shifting towards the planning of entire services and the whole customer experience related to it.

« Service design as a practice results in the

design of systems and processes aimed at

providing a holistic service to the user. »

— Chi Pham

[2]

2.1 Service Design

2.1.1 Definition

(14)

BACKGROUND BACKGROUND

The discipline takes influences from other fields like management sciences, IT, psychology or interaction design (Karpen et al., 2017; Stickdorn, 2011; Arico, 2018).

Originally, service design has been applied solely to develop more durable customer relationships and improve the service experience for the client. Since the 80s, new focusses have been set bringing

service design from just working for the final customer, considering all the stakeholders including the service deliverer itself until developing the capability to design inside the organization itself.

There are specific arguments for these developments in the past years. Service design underwent substantial changes and developments and, first of all, exponential growth. This rise in interest is mainly due to the general change of orientation from an industrial point of view towards an experience- and service-based society (Pine & Gilmore, 1998; Arico, 2018). This increased focus on customer experiences opened up new opportunities for service designers to apply their practices. A second important factor is the increasing digitalization, not just of services, but of organizations as well. Reason et al. pointed out, that the way towards digital is not just a change of channel,

but a totally “diff erent way of doing business” (Reason et al., 2016, p. 96). This shift of focus from concentrating solely on the customer to the implementation of service design as a research priority and, therefore, to aim for organizational change is a fundamental point in this work. Changing priorities in research, methods, and practices can easily upset internal structures and has a wide influence on the members of the organization and their patterns (Arico, 2018). The growing field of service design and its evolution also concerns researchers as seen in the graphic below.

Defining the key elements of service design and its work practices, there are various definitions partly overlapping. While one way of referring to service design relates to human-centeredness, creativity and iterative practices (Sangiorgi & Prendiville, 2017b, p.20), Foglieni et al. defines it as the capability of unifying and satisfying both the needs of users and the ones of the organization’s members while creating an advantage to competitors (Foglieni, Villari & Maff ei, 2018, p.18). This point of view is similar to Brown’s, that defined service design as the research for a precise balance between the needs of the user, the needs of the organizations and the feasibility of ideas (Brown, 2009).

Trying to synthesize and summarize the characteristics of service design, Stickdorn et al. identified some key principles describing the approach and way of working of service designers drawing five main pillars of service design (Stickdorn et al., 2011). The key principles listed below are following the summary of the most important service design principles created by Stickdorn (Stickdorn, 2011). In addition, the experimental approach has been added, since it becomes particularly important speaking about specific methods like testing and prototyping in the final phases of projects. Being the base for some service design methods and tools it has been included as an individual point.

1. User-centred - step into customer’s shoes

One of the fundamental approaches identifying service design is its user centred approach. User-centred defines the mindset of seeing the user as the most important aspect of the service, his needs and wants are to be discovered before designing and ideally also the testing of

prototypes should be done with real users to further identify their way of seeing the service.

2.1.3 Key elements

[Fig. 1] Number of articles referring to service design in title, keywords or abstract documents/year, Aricò (2018)

(15)

2. Co-creative - the others are the experts

Since service designers plan and improve entire services, sometimes from zero, a collaboration with insiders of different fields is

fundamental to be sure of a certain level of expertise in all fields involved. This approach of co-creation is already found in the research process and carried on afterwards in the design process to combine the knowledge scattered over departments, organizations, and teams to filter it and apply it for the benefit of the service. These co-creators can be colleagues, external partners, consultants, users, or in the ideal case a combination of organizational members, users and eventually external consultants or stakeholders.

This aspect is a fundamental shift from traditional approaches - to make intelligent use of the knowledge of one another instead of everyone getting to know everything perfectly; Nevertheless, it is inevitable for the designer to deep-dive into the issue treated, co-creating does not mean completely avoiding learning processes and new knowledge.

3. Holistic - see the bigger picture

The holistic aspect describes the attitude to take all aspects into consideration, to explore and map all connections between users, services, service providers and external touchpoints to obtain a complete picture.

Considering the user’s point of view as well as the service providers’ one, allows a more complete view in interactions. Including not just the service delivery itself, but also the pre- and post-experience, can give an impression on influencing factors not directly included in the process of service delivery.

4. Sequencing - everything is connected

Considering the whole journey of a service, all the interconnection between the different stages. The sequencing of these different elements is important to obtain a complete view, organize the service and identify problems in the flow of the elements.

Sequencing is closely related to the holistic view of service design, but highlights the importance of perceiving the positioning of the elements in the bigger picture, especially for timing and elements, that form the base of other elements following.

5. Evidencing - highlight your strengths

Services design evidences positive aspects and aims to transform happenings into experiences (Vink, 2009). This, like many service design activities, aims to stay behind the scenes, evidencing

outstanding parts of the service for the user. In many cases, the user will not consciously recognize this strategy, but notice it as a positive aspect of the service. Evidencing allows a certain guidance of the user through slight modifications in the user journey.

It can support the user in specifically noticing positive aspects of the service while eventually not paying full attention to slightly negative aspects, that are unavoidable for the service provider.

6. Experimental - fail fast, succeed sooner

Including a repetitive process, especially in prototyping, service design allows failures to then correct them for improvement. Based on this, failure is seen as a way for further improvement, for insights on what works and what does not for sure. Introducing radical changes can be risky and have to include the possibility to eventually return to the starting point with new knowledge to iterate the process for a new outcome. Diane Klein, service designer at Mayo Clinic in the US, sums up a failed project to support patients in scheduling follow-up

appointments.

«

The thing, that that failure taught us, and

I think that’s something we should always

know, is that you cannot assume why things

are working and not working. And if we

would’ve asked the patients I don’t think that

(16)

BACKGROUND BACKGROUND

Aricò argues, that the points 4 and 5 can be seen more as methods ra-ther than principles of service design, since they can be described more as actions related to or emerging from the other key principles

(Arico, 2018). Potentially, they have been included in the list of key principles to stress out their importance and avoid losing these points, since they can be grouped as methods connected to user-centered, holistic, and co-creative design, but they do not necessarily emerge from their definition and, therefore, have to be outlined separately to be certainly perceived.

Service design methods, therefore, are very oriented on identifying and discovering real user needs to then apply them to the final delivery of the service. The principles of functionality, commodity, and simplicity for the user are essential.

Another important aspect to mention is the particular attention given to the side of the service deliverer, that often remains discarded, but plays an important role for the organization.

Not just for employee satisfaction, but also the internal processes are having an oblique

influence on the final service delivery.

Following these principles, service designers make use of specific tools and methods to retrieve information from users or organization members or to map existing processes to identify weak points. All of them help to visualize and facilitate the understanding and holistic consideration of complex processes. The service design process itself is closely related to the principles mentioned above, using instruments to facilitate these principles.

2.1.4 The service design process

2.1.4.1 Phases and sequence

The precise steps of the service design process have been defined in slightly different ways and denominations of the single phases, but all schemes have a basic structure, that resemble each other. The process always begins with a research phase, that mostly is not further defined in its kind, even some researchers highlight its intensity (Morelli, 2009). Initial research phases allow in any case to deep-dive into the issue and the context to obtain an understanding from different points of view and the issue with its circumstances, that often have a relevant effect on the problem itself and the development of potential solutions. The

second phase varies the most in its description. It could be defined as a kind of reflection and development phase deriving from the research. In this step, the research is analyzed and possible solutions are

developed. Some subdivide this process of analysis and generating ideas while others see it as a single step happening

at the same moment.

The first part concentrates on analyzing the material gathered in the research phase. It needs to be structured and clustered to define the derivation and the context of a specific problem to then move on to the ideation process to find a potential solution for the explicit question identified.

(17)

The last step is usually defined as prototyping and/or testing and being particularly characteristic for the service design process, its found in all schemes as well as a period of testing with a minimal effort in the prototyping phase, but a concentration on the core of the service and how it can be tested to reveal weaknesses and compare planned to actual use. This stage might reconsider the previous phases and even include an additional research until the prototyping is successful and can be transformed into implementation.

The model illustrated by Evenson and Dubberly highlights some of the aspects mentioned in the previous section: The iterative approach of going one or more steps back if necessary and required by new findings throughout the process. Yet, the iteration crosses the different main phases including the implementation, where the displayed iteration could as well be interpreted as an experimental approach taking a step back after failures to repeat the development with the new gained insights. The model applied for this thesis has been the one of

Evenson & Dubberly (2010), that includes a continuous repetitive process of observing, reflecting on what has been observed, producing something, that then is again observed and reflected on.

The making process is then followed by socialization and

implementation. This continuous stepping back and repeating previous steps during the process allowed an adaptation to the reactions and changing circumstances during the research project to slowly move forward. It had been necessary and fruitful researching in a familiar environment of people and organization, but an entirely unknown one for embedding designing for services in this organization.

IN-DEPTH

RESEARCH ANALYSIS DEVELOPMENTVISUAL PROTOTYPING

RESEARCH

IDEATION

PROTOTYPING

Exploratory

observe

reflect

make

implement

Generative

Evaluative

socialize

refine

[Fig. 2] The service design process, own elaboration based on Morelli (2009)

(18)

BACKGROUND BACKGROUND

The process itself has been described in diff erent ways, one that is occurring frequently in literature, called the double diamond, has been created by the British Design Council and illustrates some of the principles mentioned above practically.

The initial discovery phase allows a significant enlargement of the research field, to take all eventual aspects in consideration.

After this, the problem is filtered and defined precisely in all its context and with all shades to consider during the following process together with the design brief. The following development phase allows a wide range of possible solutions, thinking in all directions possible until in the final step these solutions are distilled again to lead to a final solution.

2.1.4.2 Characteristics of the single phases

1. DiscoveryThe process of discovering the problem is necessary to comprehend the

problem and its roots as well as all the circumstances and influencing factors. A typical way to comprehend the problem is an in-depth research, that can be divided in desk research and field research. Desk research defines the research on the web or in literature to retrieve data regarding the context and similar cases. Field research is often carried out using interviews to people involved in the problem or shadowing, the silent observation of the situation where the problem is taking place.

2. Definition

The definition phase puts the material gathered during the first phase to use to extract and cluster insights, define themes and come up with a defined challenge to deal with in the end of the phase of synthesis. It is usually supported by techniques like creating aff inity diagrams to cluster insights, workshops, and mapping scenarios to then arrive shaping “How might we…?”-questions. This stage converges the broad research into a final question, that is used as a base for the following steps.

3. Development

The consecutive stage is handling the ideation and idea creation, that allows again a broader field to open up again and transform the

challenge into a solution in a divergent process. Methods typically used in this phase can be brainstormings, sketching or storyboarding. All those methods mentioned above support ideation and first illustration of potential solutions.

4. Delivery

The final point to then converge to the final point during the delivery phase. The implementation includes an iterating process of prototyping and testing followed by analysis of these tests to then improve the prototype until the final release. This final phase mainly deals with prototyping often combined with research practices like shadowing or semi-structured interviews to test the prototypes in their environment of application.

This process leaves a lot of room for adaptation according to diff erent projects and includes various methods that are further described in the following.

(19)

Service designers make use of particular tools and methods. These facilitate the work according to the principles listed above and

support the creation of work schemes. Some of these tools, their use and objectives shall be explained here to draw a more complete picture of the spectrum of service design and the way of working.

The tools are divided in the phases of the service design process, explained in the previous chapter, where the different tools are usually applied.

Shadowing

Shadowing is a technique where the researcher inserts himself in the context to be explored without revealing himself as a researcher. This allows an observation of the real situation with all its particularities. Often there are numerous assumptions about how a context is working without real insights, these insights can be collected through

note-taking, filming or photographing during the shadowing.

Customer journey map

Customer journey maps allow the drawing of the entire user pathway from his first contact with the service until the end of the experience. The exploration of the journey from the users point of view can trigger empathy and identify weak points for the user, that might not appear as weak to the service deliverer; Moreover, the complete mapping helps to see the service delivery as a whole and not just single pieces taken out of their context.

2.1.5 Tools and methods

[4]

2.1.5.1 Research

System map

A system map illustrates all the actors - service provider, stakeholders, and users - that are involved in service deliveries. The relation between all the different actors is pointed out and the single flows are divided by nature. It is identified what exactly the actors are exchanging, if information, material, or payments.

Interviews

Interviews are a way of retrieving qualitative information speaking directly to one of the actors in the system. Usually interviews are either structured, if the information to be retrieved is already defined, or semi-structured leaving space to the interviewee to narrate his experiences and adding points according to his perceptions and needs. Interviews are mostly audio-registered to avoid note-taking during the interview itself leaving the researcher the opportunity to react to his counterpart without worrying about missing important information.

(20)

BACKGROUND BACKGROUND

2.1.5.2 Ideation

Brainstorming

Brainstorming is not just, but often also used in service design to ideate around one specific issue leaving a lot of freedom to all participants without the possibility to judge and evaluate ideas.

Brainstorming usually is done around one keyword where all

participants can contribute with the associations and/or ideas coming to their mind regarding this keyword or phrase. Building connections between ideas and associations more layers are constructed, and the ideas develop further.

Prioritization map

A prioritization map allows a first clusterization of ideas by sorting them according to their feasibility and value. This can help to identify the pro and contra of different ideas and imagining them in a real context.

2.1.5.3 Testing

Could-be blueprint

The service blueprint is drawn similarly to the customer journey, but containing an additional layer mapping all the backend activities happening on the side of the service deliverer. This helps not just to plan the customer experience, but also the processes of the service deliverer, the involvement of different figures and the arrangement of touchpoints.

Prototyping

Techniques of prototyping allow a preliminary testing of new services before their final launch. Often a minimum viable service (MVS) is tested at an early point of the development to obtain insights on fundamental problems and discrepancies between projected and final use.

These insights allow improvements on the prototype to then test in again and eventually gather other findings.

The wide variety of digital and physical methods and tools present in service design allow a broad application across fields, but also create additional difficulties in precisely explaining and defining its activities in a short summary.

[4] Stickdorn, M., Schneider, J., Andrews, K., & Lawrence, A. (2011). This is service design thinking: Basics, tools, cases (Vol. 1). Hoboken, NJ: Wiley.

Narges, I. (2018). Service Design Tools & Methods. Medium. https://medium. com/capitalonedesign/service-design-tools-methods-6e7f62fcf881,

(21)

The variety of definitions and opinions about service design easily leads to insecurity and scepticism, even inside the field of service design. This ambiguity regarding a final definition makes it not just difficult to non-designers to understand what service designers are doing as a matter of fact, but also for designers to explain their workfield and tasks (Stickdorn et al., 2011).

There are several reasons for this confusion regarding the definition, often it is also related not just to vagueness regarding service design, but the design field in general and the works associated with it. Some potential reasons for this shall be mentioned and analyzed in this chapter as well as in chapter 7, where the importance of this perception in the context of design capability is analyzed.

«

If you would ask ten people what

service design is, you would end up with

eleven different answers - at least

»

— Marc Stickdorn

[5]

2.1.5 The perception of service design

2.1.6.1 Variety of fields included in the term “design”

It has been identified, that despite the huge differences among the various figures in the design field, all are being called designers making it therefore difficult to distinguish one from another

(Chamberlain et al., 2015).

This makes it easy for designers to be lumped all together, as product designers for example, since they coincide with a common idea of design.

In this given context, the perception of design is still closely linked to superficial aesthetics and the creation of physical objects, since it is a field of design that is well known. This seems to be confirmed by the aesthetical aspect of service design, that could appear as a core element at first sight. This necessary change of perception is a first, fundamental step towards the development of design capability in organisations according to Bailey (2012).

(22)

BACKGROUND BACKGROUND

Most service designers sustain, that the aesthetics of a service is not to be under-evaluated and has its importance; However, service designers are not mainly concerned about that, but the aesthetics of the outcome can make people believe, that service design is mostly about making things look good in the final steps (Stickdorn, 2011, p. 74/75; Malmberg, 2017).

The aesthetical aspect mentioned can easily be misunderstood as a core value of service design just seeing the final outcomes without getting deeper into the processes, methods, and tools of service design.

Another aspect, especially regarding in-house service design, that appears problematic both for the designers and the organization is the fact, that many service designers being hired in organizations are working on projects to deliver direct value while trying to influence the long-term business strategy with a change in culture (Bailey, 2012; Wetter-Edman & Malmberg, 2016).

The double-track challenges designers to manage their resources and time to fulfil both tasks simultaneously without losing sight of one. This applies also to the other managers in the organization: Being busy with short-term projects, frequently there is not a lot of time left to see and adapt the bigger picture (Mulgan & Albury, 2003; Bailey, 2012). Potentially leading to insecurities and excessive demands inside the design team, but also making it more difficult framing the workfield of service designers for organization members (Bailey, 2012).

This becomes essential analyzing the importance of the organization itself and its members for the service itself.

2.1.6.2 Short term implication and

long term transformation

Regarding the integration of design practices Junginger also identified conflicts with already existing design methods inside organizations, that have to be recognized as those by service designers.

Their value has to be recognized carefully balancing and

communicating the differences between the application of service design methods without a context and the kind of application that professional service designers make use of (Junginger, 2009).

«

This organizational system we are referring to

concerns the core elements of the organization

at hand: its people with their norms, values,

beliefs and behavioural patterns; its structures,

which includes procedures, hierarchies and

tasks; its resources and an organization’s vision,

which gives purpose and guidance for how

resources might or might not be used. We argue

that services cannot be isolated from these

elements.

»

— Sabine Junginger & Daniela Sangiorgi

[6]

[6] Junginger, S., & Sangiorgi, D. (2009). Service design and organisational chan-ge. Bridging the gap between rigour and relevance. In International Association of Societies of Design Research (pp. 4339-4348). KOR.

(23)

There is a growing trend and need among designers and managers to introduce service design practice into organizations as pointed out already in chapter 2.1.2.

Junginger and Sangiorgi argue, that taking the entire organization, their members, and background in consideration is fundamental, since the organization itself is the core of the service and all decisions or

guidances derive from the network of the organization and its members (Junginger & Sangiorgi, 2009).

Junginger found service design already “deeply embedded in

organizations” (Junginger, 2009) arguing, that every organization offers something, that needs to be developed like products or services. The development of a service or a product in an organization implies, that there are already some design practices used.

But the application of these practices often lacks expertise and correct application.

Following this assumption, it can be said, that there is no such thing as an organization without any trace of design. Junginger does recognize the value of this fact, but also argues, that this previous application and already common practices, eventually without awareness, need to be recognized by designers. Through recognition of the already common practices and potential connections to design, the starting point and the circumstances to further build design capabilities can be defined. Junginger also mentions, that the existing traces of design can be helpful on one hand, but their unstructured nature can cause difficulties in the knowledge transfer process on the other (Junginger, 2009).

Surely, this existence of design in organization has to be distinguished by different levels of depth of implementation, but the importance of the organization itself is undeniable.

However, there is a lack in defining how those different factors inside the organization can be handled in a practical experience adapting tools and methods to the current level of design capability to then increase it.

This thesis aims to explore in one specific case the perception of service design and its level of embedding in the organization to then reflect on potential ways to adapt and introduce new tools demonstrating the application of service design in one specific case and potentially improve the design capability.

This shall be further elaborated in chapter 7 in direct relation to the theoretical framework.

(24)

BACKGROUND BACKGROUND

Referring to this statement made by the World Health Organization, health is not simply defined as the absence of illness, but taking in account all the factors, that influence the well-being of humans; Therefore, healthcare includes all kinds of treatments and care that ensure and foster health, not just treating symptoms of ill-being and the cure of already existing problems, but also to prevent future ill-being. It does not just impact on the personal well-being, but at a certain point it also influences the impact on society in cost, workforce,

and use of services (Ortiz-Ospina & Roser, 2018).

With this consideration, the concept of health becomes a lot more complex influencing various factors out of what is frequently associated with the healthcare sector. Going far beyond the borders of pure healthcare services, this system goes far beyond the topic of healthcare. A scheme published by the Department of Health of Minnesota, US, illustrates the general factors influencing the health of humans. The healthcare system occupies a relatively small space, while the socioeconomic environment, physical environment and health behaviours have the most influence on health.

Even genetics and biology, factors completely out of reach, determine the health state. It is also notable, that at the center, there is not just the single person, but together with his community and family, that, therefore, play a role as important as the one of the individual itself. Regarding these definitions, this study mainly concentrates on the area of healthcare with a quick view on health behaviours, that could be, at least partly, defined as self-care and/or prevention speaking about nutrition, exercise or alcohol and drug consumption.

«

Health is a state of complete physical, mental

and social well-being and not merely the absence

of disease or infirmity.

»

— World Health Organization

[7]

2.2 Health and healthcare

[7]defined by the World Health Organization, Official Records of WHO, no. 2, p. 100

(25)

2.2.1 Trends and tendencies in healthcare

The main challenges as identified by the European Commission in their eHealth action plan for the years 2012 until 2020 is mainly the growing health expenditure due to the ageing society and its needs for more intensive care and a rise of cases of chronic diseases.

All this is expected to be a burden for the public services and requires reformations of the healthcare systems (European Commission, 2012). In the last years, there have been evolving some general tendencies related to societal changes that are significantly influencing healthcare and its related organizations with their strategies on how to enlarge and improve their service offer. Some of these tendencies are to be

described and briefly analyzed in the following.

1. From passive to active patients

Closely connected to the trend towards prevention of diseases and illnesses, patients need to be actively part of their cure.

It is not just about being cured anymore, but understanding the system and different steps of the care process as well as gathering information on how to prevent future ill-being.

The web is just one of the sources, that give patients access to

information. The latest report on eHealth states, that more than 80% of the countries providing eHealth are using social media to promote their care systems and inform patients. These channels are easily accessible to everyone and could even be argued to potentially support the Universal Health Coverage (UHC).

The concept of Universal Health Coverage wants to provide healthcare to everyone totally independent from origin, financial or social status. All WHO members committed on aiming for this total coverage (World Health Organization, 2016).

Most prevention cannot be implemented without an active interest and contribute by the patient itself, since it usually does not happen in a medical context, but in daily life.

(26)

BACKGROUND BACKGROUND

3. Growing expenses

The public health expenditure rose from about 6% of the GDP/capita up to 7,2% in the last 20 years, and it could rise up to 8% in the next 40 years.

This rise is mainly due to the ageing population and the growing presence of chronic diseases, that requires higher health expenditures per capita.

2. E-health

EHealth, the provision of healthcare using or supported by electronic devices or communication, is quickly expanding.

Eff ective use of eHealth can support personal care for example monitoring the patient and providing this data to the doctors. Also eHealth is closely connected to the need for prevention and well-being as well as the activity of patients. Patients are given the possibility to monitor and improve their lifestyles with digital support. In 2016, more than 50% of all WHO member states had an eHealth strategy and more than 90% of these strategies was compliant to the concept of Universal Health Coverage (UHC) which aims to make healthcare accessible to everyone, not just upper classes of society (World Health Organization, 2016).

Problems in the further development and the distribution of eHealth are mainly the high initial costs and missing trust or understanding of use from the patient’s side. There is also still a lack of integrating eHealth solutions with in-place healthcare (eHealth Action Plan, 2012).

Not just patients are facing the changes of integration of eHealth, also healthcare organizations are forced to adapt to these changes, implementing own eHealth solutions and facing new competitors in that sector. At the same time, it seems an attractive solution for

a cost-eff ective treatment for monitoring and treating high numbers of patients (Dolicanin & Kajan, 2015)

The development of eHealth services can also be seen as a reaction to the changes in the healthcare system (Praities, 2017).

Editor Nigel Praities sees the evolution of digital healthcare services at least partly as a consequence of the latent privatisation of the

healthcare structures in the UK (Praities, 2017).

The healthcare system has to adapt to the growing need for care and the slowly, but steadily increasing patient volumes

(World Health Organization, 2016).

At the same time, the growing costs are requiring not just additional structures to respond to patients’ needs, but at the same time new solutions to provide more eff icient care at an eventually lower cost. These are often closely connected to eHealth solutions mentioned in the previous point to increase eff iciency and quality of treatment. Being strongly influenced by society, healthcare undergoes constant changes following the societal ones.

Service design is applied more frequently also in the healthcare sector to respond to this need of change.

(27)

Designers have been introduced in the healthcare sector originally mo-stly for product development or communication design

(Tsekleves & Cooper, 2017), not being directly in contact with other departments and mostly not sharing their techniques or collaborating, but with the scope of delivering a finished product,

something ready-to-use, without a widespread research directly in the area of application and a close collaboration with other departments. More recently it has been discovered, that designers can bring in methods to engage with patients, members of the organization and stakeholders to go beyond single product developments being a driver on the way forward in a fundamental change of the entire system (Chamberlain et al., 2015).

2.3 Service design in healthcare

2.3.1 Design in healthcare

The healthcare sector is more and more interested in integrating design in its practices (Tsekleves & Cooper, 2017) with different goals

according to the kind of structure where design is implemented. Some main fields of action, quite different one from another, have been identified:

(28)

BACKGROUND BACKGROUND

1. Acute treatment and emergency care

The emergency and inpatient part deals mostly with hospital-like organizations, here design is mostly implemented to increase eff iciency and eff ectiveness of procedures while keeping the clinical quality extremely high that are oriented towards eff iciency and eff ectiveness.

2. Long term and preventive care.

Outpatient clinics and organizations taking exclusively care of

prevention are seeking for design in their systems to provide seamless patient journeys, transparency, and keeping patients loyal while identifying emerging trends to meet the needs of the patients.

The development of new services based on real user needs can take advantage of design research to identify those needs and then ideate potential solutions.

Preventive care is closely related to lifestyles and habits, that need to be understood to understand how to build a consistent relationship with patients not just curing their illnesses, but promoting prevention and supporting patients in actively following it.

Also other long-term care processes like the treatment of chronic diseases requires a deep understanding of patients’ habits, needs, and diff iculties to off er the best possible support in all stages.

To be able to off er this care at 360°, medical structures need to

understand not just the needs, but also the adequate channels to keep in touch with the patients over a longer period (Tsekleves & Cooper, 2017).

Not just about their care plan, but influencing their entire lifestyle. Tsekleves and Cooper identified 5 trends emerging in design for healthcare, that are all based on a patient-centered care as its core.

1. User-centered approach

In this context, there have been studies conducted that state, that also the user’s prior experiences are influencing the way what is needed in a service and what the users will expect (Wetter-Edman et al., 2016). To retrieve and utilize this information, the user has to be made an active part of the design process, the process has to include the user,

not just be made for him.

There are certain diff iculties in getting hands on concrete and to forecast how the happenings planned for the service will transform into experiences for the diff erent user types (Bate & Robert, 2006).

The user, therefore, shifts from being a silent actor to being an active member during the development of the service (Bate & Robert, 2006).

2. Self-management healthcare

Apart from the further development of the user-centred approach in service design, there is another emerging trend, that has already been mentioned from the healthcare perspective in 2.2.

Self-management healthcare, which is emerging from the patients’ growing interest in actively contributing to their health and the entire care process. In this way he is enabled to support these activities. Service design can contribute to this enhancement.

3 Community healthcare

Community healthcare as a way forward in grouping patients with common needs and to provide a more adapted care being still as eff icient as possible. Community healthcare does not just allow to group people with similar necessities, but getting them in touch with each other, it can also support self-management care and opens up eventual possibilities for collaboration and exchange within the community built.

(29)

4. Holistic healthcare

Holistic healthcare has already been listed in chapter 2.2 speaking about trends in healthcare: tending to provide a more complete care process, not just curing single health problems, but finding eventually connections and striving for preventative healthcare to then undertake the whole process of well-being with all its factors and consequences. Holistic healthcare is a broad field including a giant network of actors and influencing factors wanting to take in consideration every aspect, that influences health in some way.

5. Prevention

Prevention and health promotion is, however, closely linked to holistic healthcare taking in consideration also the causes of potential ill-being and its possibilities to prevent these states, that then require treatment. Preventional care takes a close look at habits and lifestyles while analyzing risks and how regular check-ups can lower those risks for ill-being.

Having a look at the trends in healthcare (chapter 2.2.1) and the ones of design in healthcare (chapter 2.3.2) the tendencies can easily be related to each other and to the methods of service design. The trends in chapter 2.2.1 are correlated to the development of society, that has already been identified going into the direction of a service-based society (Bate & Robert, 2006).

Most issues in the healthcare context can be defined as what Buchanan calls „wicked problems“ (Buchanan,1992; Malmberg, 2017).

This refers to problems, that are not resolvable with one ideal and easily applicable solution for their complexity, since there are too many factors involved for a perfect solution to exist.

The creative approach of service design can be a way to improve the situation for the organization and the patient (Chamberlain et al., 2015). Service design has been identified to be a potential solution to the strongly needed change in healthcare (Fry, 2017).

Its systematic and holistic attitude includes patients as well as

stakeholders in the process. Also, it sees patients and stakeholders not just as part of the research, but as resources to generate new ideas and develop new services (Fry, 2017).

Some specific aspects of service design, whose nature plays an important role in service design for healthcare shall be illustrated in the following.

(30)

BACKGROUND BACKGROUND

1. Experience-based design

Analyzing the potential contribution of service design in healthcare, Vink et al. found, that experience-based design is a valuable source to improve services in healthcare. Experience-based design uses mainly qualitative research techniques to collect real experiences of user. These real experiences are then utilized as an inspiration for the betterment of the service. Stakeholders and staff are seen as equals here and their experiences are collected as the ones from patients. Typical methods applied in experience-based design are interviews, shadowing, photo journals or focus groups. The data collected from this phase then needs to be understood and transformed in specific insights, that allow the evolvement of concrete proposals of change.

2. Prototyping

Prototyping allows testing ideas before definitely implementing them. In a sensitive environment like healthcare, reactions and outcomes are difficult to predict while changes can have a huge impact on the service. Testing a Minimum Viable Service (MVS) with single patients allows preliminary insights about the basic functions of a service and a comparison from planned and realistic use while collecting insights on the perception of users.

This process can be iterative until the final implementation.

3. Co-design

Co-design defines the development of a new service, or the reformation of an existing business together with users and/or stakeholders. The different actors are involved not just during the research, but also in the ideation phase. Potential users of the service can provide insights on what customers would really wish for, what are their ideas and first insights on how people could react to certain changes in fact.

The healthcare sector is dominated by organizations based on

system-thinking, but especially in this kind of companies, design-based thinking is still often seen as a contrast to the commonly used methods (Bailey, 2012).

Differences of tools and way of thinking lead to skepticism and requests also an investment of time and resources to be trained. Without this investment, the methods of service designers cannot be understood and risk, therefore, to be left unused. This aspect shall be elaborated further in chapter 7;

Nevertheless, service design is slowly making its way into healthcare. The service design network treated the argument in its report regarding service design in healthcare published in late 2017.

The authors sustain, that service design is becoming fundamental for healthcare to further evolve and meet the needs of markets and patients (SDN, 2017).

Various sections go in detail on the main issues identified like Service Innovation, eHealth, Organizational change and capability building or the engagement of communities and patients (SDN, 2017). A survey conducted inside the service design community identified the difference work fields of service designers in healthcare all over the world. While 93% of them were somehow engaged in the patient journey, just 7% of the projects targeted the structures themselves.

(31)

However, service design seems to have an impact on company culture even in projects originally targeting the patients;

about 46% of all projects seemed to have an impact on company culture and the members of the organization.

This side eff ect of organizational change could be a result of the specific characteristics of service design like considering all influencing factors of a service, that necessarily includes the organization, its members and potentially also its internal structures and systems. Concluding it can be said, that service design is often integrated in organizations for single projects or with a specific target regarding the service itself, but resulting in an impact on the organizational culture. This change in the organization itself and not just in the service delivered is closely related to the structure and culture of the

organization, their individual members, an integration not just of service design, but also its methods and the deployment of design capability. 17%

POST-CARE AND MAINTENANCE - treatment maintenance - commodities management - treatment discontinuation

24%

PRE-CARE AND PREVENTIVE - general wellness, lifestyle - de-stigmatisation of illness - prevention, awareness - pre-diagnosis - diagnosis, treatment, decision-making - preparing ofr treatment

25% GETTING CARE - treatment - acute care - emergency intervention - palliation 27% ENTIRE JOURNEY - pre-care and preventive - getting care

- post-care and maintenance

7% OTHER - relating to infrastructure - internal workingrunning of a healthcare organisation 133 responses (about 680 projects)

Policy and regulation

Education and capability building Citizen/patient engagement Cultural change

Organisational change

(32)

BACKGROUND BACKGROUND

The previous chapter specified the positive impact, that service design can have on organizations and the growing number of in-house design labs in healthcare structures confirms this tendency to face the changing environment in healthcare differently (Molloy, 2018).

In the past, the healthcare sector referred to approaches from other fields like lean or Six Sigma, but the scale requires new approaches towards innovation (Molloy, 2018, Bevan and Fairman, 2011).

This need triggered the trending implementation of service design as a driver for innovation.

Analyzing 17 health labs, Molloy (2018) divided their aims in two different directions:

One to change the culture of an organization, its way of evaluating and working while the other is concentrated on accelerating innovation at the inside of an organization (Molloy, 2018). Even being different in their final outcome and goal, the two directions can be combined in their process (see 2.1.5). Both agree on the point, that service design can help to innovate, test and eventually scale new solutions.

The labs taking the direction on innovating the service offer of the organization are solely focussing on this part trying to adapt the service to the emerging needs in healthcare and scaling up.

While the ones also oriented on culture change argued, that design shall not just be practiced within the design team, but provide methods and tools to research and co-create with other members of the organization. This could lead to these members potentially using design tools and methods on their own at a certain point. The capability to do so can be roughly defined as design capability, even though there is ambiguity regarding the definition of design capability, that shall be further elaborated in chapter 6.

(33)

One basic principle of the adoption of service design is surely acceptance to allow a certain level of openness to leave room for integration. Since service design introduces new methods to reveal weak points in the system or to improve it in general, especially in the beginning other seniors may feel criticized by the results of the

analysis.

This is not just related to the approach of the organization, but it has been found to be also closely connected to the designer’s attitude towards the existing capabilities. Mulgan found, that trying to prove their competences, designers tend to not recognize the present values (Mulgan, 2014). This mutual scepticism can lead towards a vicious circle of the designer trying to give proof of his unique competences, and the others members of the organization seeking to communicate the existing qualities. This awareness and two-sided respect and

acceptance mentioned above is fundamental to be then transformed into interest, that is fundamental for the development of interest in developing design capabilities.

One scheme to define the level of integration of design is “The Design Ladder”, developed by the Danish Design Centre to illustrate the process of the adoption of design in organizations. While in the first step, design is completely invisible or non existent, in the second one it just functions as a final formgiving, an exercise of styling without any influence of processes or development.

The shift happens between the second and the third step where design is turning into a process.

Apart from not just being an aesthetical aspect anymore, design in this stage changes from being present just in the final stage to being present throughout the whole process from the very beginning. This represents a fundamental change not just in the presence of design related to various phases of projects, but also the perception has to change radically from seeing design as a refinement of

aesthetical aspects to a steady part of any development from the idea until the realization.

STEP 1

NON-DESIGN

Design is an invisible part of, e.g., product development, and the task is not handled by trained designers. The solution is driven by the involved participants’ ideas about good function and aesthetic. The users’ perspective plays little or no role in the process.

STEP 2

DESIGN AS FORM-GIVING

Design is viewed exclusively as the final form-giving stage, whether in relation to product development or graphic design. Many designers use the term ‘styling’ about this process.

The task may be carried out by professional designers but is typically handled by people with other professional backgrounds.

STEP 3

DESIGN AS A PROCESS

Design is not a result but an approach that is integrated at an early stage in the development process. The solution is driven by the problem and the users and requires the involvement of a wide variety of skills and capacities, for examples process technicians, materials tecnicians, marketing experts and administrative staff.

STEP 4

DESIGN AS A STRATEGY

The designer works with the company’s owners/ma-nagement to rethink the business concept comple-tely or in part.

Here, the key focus is on the design process in rela-tion to the company’s business visions and its desi-red business areas and future role in the value chain.

[Fig. 11] The design ladder - The Danish Design Centre

15% 17% 45% 21% 36% 13% 35% 15% 2003 2007 % of companies, 2003 % of companies, 2007 1 2 3 4 2 1 3 4

(34)

BACKGROUND BACKGROUND

Aricò reviewed this model created by the Danish Design Centre slightly changing the diff erent steps and adding the actions, that need to happen in each specific phase to evolve further in the specific context of a service organisation.

The model is structured in the same way as the design ladder, but, instead, taking the perspective of the organizational members.

Not focussing solely on the role, that design plays, it takes the actions of the designer trying to build design capability in account.

Basing on the conclusions by authors like Cohen & Levinthal, that have found the people in the organization to be the determining factor in adopting design on an organizational level, not just the philosophy of the organization itself, the model is revised (Cohen & Levinthal, 1990; Aricò, 2018).

The target of each phase is described synthetical way together with the diff erent, slightly more detailed actions, that the designer takes to achieve this. Starting with a process of sensibilizing to service design by modification and adaptation of tools and methods while simply displaying the outcomes and work processes of service design projects. In the second part, the more passive introduction phase migrates to a slightly more active part, where designers seek to actively integrate design practices and engage the application of the methods and tools while pushing the process of making people knowledgeable forward. After a first adoption has been achieved, the further development needs to be observed, tracked, and a certain specialization can take place in this state anchoring service design as a part of the organization. The final step examines the ongoing growth of design capability, evaluating the eff ectiveness of the implementations and measuring in some way the gained capabilities.

4

Enabling structures

3

Dedicated human resources

2

Enactment of SD practices

1

Awareness of SD principles Evaluate Measure Incentivize Grow Track Specialize Secure Locate Engage Familiarize Embed Customize Simplify Expose Sensitizing

Riferimenti

Documenti correlati

DLBCL, diffuse large B-cell lymphoma; IPI, international prognostic index; aaIPI, age-adapted IPI; PMBCLs, primary mediastinal large B-cell lymphomas; R-CHOP,

More than thirty years ago, Bjorken suggested a possible way to detect the creation of decon- fined QCD matter in collisions of ultrarelativistic nuclei: due to interactions with

They were tested with clinical scales (neuropathic pain scale inventory (NPSI), numerical rating scale (NRS), modified Ashworth scale (MAS) and with the nociceptive withdrawal reflex

Se, quindi, l’esercizio delle prerogative dello Stato del porto risulta legittimo alla luce delle norme consuetudinarie e pattizie sul diritto del mare, e nonostante le misure

La bibliografia sul tema delle basiliche circiformi e le loro funzioni sepolcrali è molto ampia, e annovera contributi di importante valore storiografico come Krautheimer 1960

Scrivere una storia della “coscienza”, nel II libro dell’Einleitung, assume un doppio significato. Storia della coscienza come genealogia delle strutture che si sviluppano nel tempo,

Hazard ratios (HRs) for all outcomes of CE (major CE, myocardial infarction) and CBVD (major CBVD, ischemic and hemorrhagic stroke) and tertiles of RII, using the first tertile as

- the shear strength values by EN 1193 specimens, resulting systematically higher, even if the way of shear breaking was very similar to the full size joints, indicates the limits of