Be Like Water: Strategies for infusing design in healthcare organizations

Earlier this year, Katie McCurdy and I gave a presentation about our design work in healthcare at Interaction Design Association’s annual conference, Interaction17, in New York City. We shared several case studies in order to demonstrate how our approach is slowly permeating the UVM Medical Center, and changing its culture along the way.

Picture a large academic medical center full of passionate and committed people — nurses, doctors and many other staff — who feel constrained by a rigid and hierarchical environment that doesn’t always support the best user experiences for patients or employees. Now imagine two lone designers trying to make a difference in this setting, navigating a dense bureaucracy, looking for kindred spirits and building productive partnerships across silos. In this talk, we share stories of how human-centered design can infuse humanity and bring about cultural change within a hospital, mediating organizational needs with those of end users who may be stressed or vulnerable.

We discuss projects that span the design of systems, clinical processes, services, environments, digital interactions, and printed materials. These vignettes show how we have used generative, participatory, and action-oriented methods and tools to creatively and empathetically solve complex healthcare problems, all the while changing perceptions of what work looks like. Learn how human-centered design can help bring the human scale back to the heart of our healthcare institutions.

Here’s a video of our talk:

“Design Is Culture” Presentation at HXRefactored 2016

Earlier this year, I participated in a panel discussion “Designing within a healthcare system: challenges and strategies” at HxRefactored 2016 on April 5, 2016. This post is rather late, but here are the slides on this page to my talk “Design Is Culture,” which builds upon my earlier article “Design Tools for Social Engagement in Organizations”:


My leap into the unknown

After seven years of teaching art and design full-time at The University of the Arts

in Philadelphia, last month I left academia to work as a designer in a large medical center. Last week I started as an experience design strategist at The University of Vermont Medical Center in Burlington, a large teaching hospital with over 7,300 staff and 450 inpatient beds where I had understand what the reviewing tinnitus 911 was about. The transition is huge, not just for me but for my family, and we all left a lot behind in Philadelphia — family, friends, colleagues, a supportive community — to embark on this professional and personal Vermont adventure, which brings many unknowns.

The opportunity is a challenging new phase, and for me it builds upon a wealth of experiences, learning, and doing in the realm of social design, social practice, and community organizing. With my new role as designer embedded in a hospital, I’m not exactly sure how all of these threads intertwine, but I know that they have informed the practice and methodology which I bring to this environment. The truly exciting aspect of this work is being intentional in how the threads do intertwine within the scope of my role. I’ve been given a great deal of autonomy here to find willing partners interested in applying human-centered design to better people’s experience as patients, but also support their longterm health and wellbeing. And I am humbled by the potential and responsibility of my contribution to the domain of healthcare. As I dig into the work, I hope to continually share what I learn through the process with collaborators near and far.

I’m grateful to all of the friends, family, and colleagues who have supported me in getting to this point. This group of people includes fellow faculty at UArts and other design colleagues who have taught me a helluva lot about designing with the people we wish to impact. It also includes family members who have had to endure difficult experiences in healthcare and have therefore revealed so much to me about why this next phase of my professional life is so important and meaningful.

Design Tools for Social Engagement in Organizations

This article originally appeared in OD PRACTITIONER Vol. 47 No. 3 2015, a journal published by the Organization Development Network, and is reprinted here with permission. Special thanks to my colleagues and graduate students from the Design for Social Impact and Industrial Design programs at The University of the Arts, without whose work this article would not have been possible.


Design thinking is valued within the business world because it contains a powerful set of methods and tools for creative problem solving and catalyzing innovation in many different sectors (Brown, 2008; Martin, 2009; “Design Thinking…”, 2006). Following from this recognition, designers and design innovation consultancies are increasingly being asked to contribute to the (re)design of organizations, where an inclusive, multi-stakeholder design process can have a significant impact on individual mindsets in support of large scale organizational culture change. In particular, social engagement tools that emphasize visual communication and embodied interactions have the power to reorient organization dynamics. By combining this design-led approach with organization development’s deep expertise in change management, there is immense opportunity for reciprocal partnerships between OD and design professionals.

In this paper, I will briefly recount the expanding scope of design within a recent history in order to track its disciplinary evolution. I will then expand upon the characteristics of design culture as it relates to organization development. Finally, through case studies, I will discuss how design tools for social engagement can change the nature of collaboration and communication within organizations, and what this suggests for future partnerships between designers and organization development practitioners.

The expanding scope of design

The boundaries and scope of problems addressed by designers has continued to expand over the last half century. Designers increasingly have applied their creative problem solving methods and “design thinking” process to issues beyond the realm of products and visual communication, addressing processes, systems, services, strategy and culture. The long view of this historical shift in design practice has been tracked by Richard Buchanan who characterized the discipline as practicing within four distinct “placements” over the last hundred years of its brief history (1992). Tony Golsby-Smith furthered refined Buchanan’s four “placements” by describing these as expanding “orders” of design practice, which he contextualized through specific practical applications within widening domains (see fig. 1.) (1996).

Figure 1. The four orders of design

Figure 1. The four orders of design

The first order concerns the design of text and image (words and symbols), which is most readily identified with graphic and communication design. In the second order, designers primarily give form to objects, creating industrial and commercial products for mass markets. In the third order, designers apply the creative problem solving process to the strategic planning and operations domain in order to bring a heightened level of efficiency, responsiveness, and even innovation to the production, marketing, and user experience of products and services. The expanding role and impact of design continues into the fourth order, where designers move beyond the details of industrial processes and consumption to address issues pertaining to systems and culture. Ultimately, the story of design thinking’s rise over the past several years is about building multi-disciplinary teams with the capacity to confidently navigate complexity and address seemingly intractable problems with a new set of highly collaborative and creative tools and methods.

Social design

Even more recently, a finer distinction has been suggested by those designers who primarily take on complex social entities, relationships and systems as a problem space in which to work, which may be described in a number of ways: design for social impact, design for social innovation (Manzini, 2015), transformation design (Burns, Cottam, Vanstone, & Winhall, 2006), or social design (MICA Social Design, 2014). The definitions of these terms are by no means settled, and each one implies subtle distinctions. For the purposes of this paper, I will refer to social design, which describes a distinct, although emerging, sub-discipline with an expanded set of competencies for its practitioners.

Social designers require more developed skills of emotional intelligence and organizational sensitivity along with appropriate tools focused on facilitation and collaboration with a variety of different stakeholders, most of whom are non-designers. Often referred to as co-design, involving stakeholders throughout every step of the process fosters creativity and collaboration from the earliest stages of design research through rough prototyping, to testing and evaluation of design proposals and outputs (Sanders & Stappers, 2008). It is here where I see the most potential for productive, reciprocal partnerships between design and organization development.

Design meets culture

I have recounted above a brief history of the design discipline’s expanding sphere of impact to include the domains of organizations, systems and culture. An essential opportunity and consequence brought on by this shift, though, has been the transference of certain key design competencies to the organization and community partners within any given client engagement. This transference, facilitated by a highly collaborative, participatory process, is ultimately a means to establish a design culture within an organization.

While the celebration of design thinking by influential members of the business community may begin with a focus on more creative ways to innovate and respond to a volatile, uncertain future, it is also about changing how organizations function, communicate and collaborate across established silos. Introducing design thinking into organizations is, and should be, about building an internal culture of design. Here I use design culture instead of design thinking in order to better describe a set of practices and behaviors — an organizational mindset even. As a detached set of methods and tools, design thinking is often deployed ad hoc, initiated as one-off engagements (design workshops) or project-specific consultancies, which may or may not become sustainable within an organization over the long-term after the first contact. Nurturing design culture suggests a more permanent transformation in the way an organization and its members do their work, as well as their attitudes toward collaboration, failure, learning and ambiguous problems.

There is not a single, correct definition of design culture. Nor will a culture of design within one organization be expressed in the same way in another organization. However, it is useful to outline what the term means by articulating several values that are essential in the promotion of a design culture (see table 1.) (Brown, 2008; Buchanan, 1992; Cross, 2011; Kolko, 2011).

Design Values Expressed by
Generative, solutions-focused, optimistic Seeing constraints as opportunities
Brainstorming, thinking outside of the box
Divergent thinking
Action-oriented and experimental Learn by doing
Making, prototyping
Empathic Talking to and listening to people
Understanding the experiences of people
Reflective Self awareness, evaluation, learning
Integrative thinking Systems thinking
Synthesis and sensemaking
Employing abductive reasoningInformed Intuition
Collaborative Interdisciplinary
Inclusive and participatory
Visual Using non-verbal modelling media
Visual thinking and visualization

Table 1. Design values that promote a design culture

Case study: IBM Design

I turn now to a high-profile example of an organization that is remaking itself through a culture of design. In the last few years, IBM has reoriented itself around design-led innovation and human-centered design process (Lillington, 2015). The goal is ambitious and transformative: infuse a strong design ethos within a multinational enterprise software and business operations corporation.

At the heart of this mission is design education, the transference of design process, methods and tools through project-based experiences. New hires fresh out of undergraduate and graduate design programs are brought to IBM Design’s Austin, Texas studio for an intense 3-month design camp during which they are oriented to the organization and culture, assigned to various product development projects, and pushed to quickly deliver results within a highly complex, iterative and rigorous enterprise environment.

Expanding beyond the confines of the design studio, members of IBM Design’s Education and Activation unit travel around the world to other IBM sites to facilitate week-long design workshops with product development teams, most of which are already integrated with IBM designers. The goal of these engagements is to, again, transfer aspects of design thinking and human-centered design process by working closely with developers, engineers and managers, by modeling and reinforcing those values so important to design practice.

The dissemination of design culture at this scale is ultimately a massive organizational change initiative. It is fascinating, not so much as a strategic goal, but in practice, in the specific methods, behaviors and relational work being done to meet this goal. The question remains to be answered, of course, about the net effect and impact of IBM’s reorientation around design, as judged by its key business metrics. How successful will the establishment of a new design culture be in transforming the organization?

An opportunity for organization development and design

The IBM example represents a design-led approach to organizational change through the creation of an internal design culture, which makes sense given its strong legacy of design. For many organizations, though, different engagements with design will be required to achieve culture change because the opportunities may be more rigidly defined within the framework of organization development. Organization development practitioners will be sought by companies to help frame the questions around organizational change, establish the protocols for managing change, and facilitate a multi-stakeholder process. OD practitioners have decades of experience and collectively amassed huge portfolios of clients and change management projects, working both externally and internally.

Designers and design innovation consultancies (eg. IDEO, Continuum, Catapult Design) are increasingly playing similar roles as design becomes valued for its ability to steward change in the realm of organizational culture (the fourth order of design). Rather than following an either-or scenario in which the relative effectiveness of each discipline’s approach is judged against the other, I believe that there is immense opportunity for reciprocal partnerships between OD and design professionals. In particular, social engagement tools that emphasize visual communication and embodied interactions have the power to reorient organization dynamics by instituting a design culture.

A number of studio projects undertaken in the Design for Social Impact (DSI) graduate program at The University of the Arts in Philadelphia (where I am currently the program director) have pointed to this OD and design partnership opportunity and suggest the need for more refined and focused test cases to model such a partnership. DSI graduate students, led by experienced faculty, have engaged partner organizations in addressing a range of organization and systems-level issues. In dealing with complex, ambiguous problems, the DSI design teams have often touched upon (sometimes reluctantly) challenges regarding organizational culture change. In fact, the program relies on faculty and visiting lecturers with expertise in organization development, organizational psychology, and community organizing to mentor students in navigating complex community and organization dynamics.

The DSI program has been involved in several projects (“Design for Social Impact…”, n.d.) in partnership with the University of Pennsylvania Health System (UPHS), one of the leading health systems in the nation which includes three major hospitals in Philadelphia as well as an array of clinical practices across the region. Through graduate thesis and design studio projects, students have worked with PennMed’s Center for Health Care Innovation and the Performance Improvement in Action teams. These projects have focused on organizational dynamics and change, patient services and customer experiences, and the role of design in fostering innovation within health care. The long-term goal of these partnership projects with UPHS has been to improve the quality of care it provides by slowly and incrementally introducing designerly behaviors and practices which foster new approaches at all levels of staff.

One student project in particular addressed the issue of organizational culture change at UPHS. In 2013, DSI graduate student Benjamin Hillson joined a team of cardiac nurses within the framework of UPHS’s Performance Improvement in Action (PIIA) cycle in order to discover an opportunity for innovating a process directly connected to the nurses’ work. (PIIA invites teams to compete in an “innovation tournament” style process to improve an aspect of the team’s work and measure its impact.) Hilson’s role was largely that of designer-facilitator, assisting the nurses in establishing a process for discovery and problem finding, ideation and prototyping, and evaluation and iteration of design-driven solutions. The nurses had identified a problem stemming from inconsistent, inaccurate information being communicated to cardiac surgery patients, and they were eager to improve it (Hillson, 2013).

Along with his knowledge of co-design — action research, co-creation, rapid prototyping and iteration — Hillson introduced highly visual and embodied tools and methods to the nurses to support an evolution in their work. These tools and methods included: large-scale brainstorming sessions captured with visual notes and sketching; visual frameworks for making sense of user research, ideas and processes through mapping; and lo-fidelity paper prototyping that allowed the team to quickly visualize possible solutions and gauge their effectiveness (see fig. 2.). Apart from the specific project outcome — a better process for communicating the care plan to cardiac surgical patients supported by visual artifacts — the nurses responded positively to a different way of working that was optimistic, highly engaging and collaborative, and proactive.

Figure 2. Communication materials generated during the prototyping process (photo credit: Ben Hillson)

Figure 2. Communication materials generated during the prototyping process (photo credit: Ben Hillson)

Another long-term DSI partnership has been with 1199c Training Fund (“Design for Social Impact…”, n.d.), a non-profit organization which provides free basic job skills training and professional development for members of a local healthcare workers union. The 1199c Training Fund initially reached out to the DSI program to help them understand their membership’s educational needs with the goal of improving the visibility and communication of these offerings and increasing enrollment. A subsequent project addressed how the Training Fund’s physical reception area and intake system functioned in order to learn how improvements might be designed and implemented. The most recent project built off of previous insights in order to design a feedback system and supporting artifacts which would help improve their curriculum, course offerings and teacher effectiveness.

Figure 3. An oversized die to help teams ask challenging questions

Figure 3. An oversized die to help teams ask challenging questions (photo credit: Design for Social Impact)

Figure 4. A Physical Prototyping Kit to Help Teams Visualize New Ideas

Figure 4. A physical prototyping kit to help teams visualize new ideas (photo credit: Design for Social Impact)

The Training Fund staff have demonstrated a particular openness to the design process and a willingness to experiment with different formats. The various graduate student teams working with them took advantage of this high level of trust and commitment to collaboration in order to develop tools which emphasize visual communication and embodied interactions. Some of the tools that students prototyped include: a three-dimensional mapping tool to visualize communication channels; an oversized die to help ask challenging questions in a less vulnerable way (see fig. 3.); a physical prototyping kit to help staff visualize new ideas (see fig. 4.); role playing exercises to enact aspects of the Training Fund’s communication processes; and an object for capturing feedback (see fig. 5.).

In the workshops where these social engagement tools were used, the Training Fund staff were visibly energized by this more active and visual way of working together to address complex issues within the organization. Notably, they looked forward enthusiastically to the design workshops, and they specifically asked to keep the tools after the lifespan of the projects. For an organization where discussion-based meetings are the normal way of operating, the introduction of these action-oriented methods seemed a welcome shift towards a more design-oriented culture.


I offer these two case studies not as definitive proof but rather as support for further exploration of the potential of promoting design culture within organizations. What is clear is that a design thinking process reinforced by visual and physical artifacts and interactions has the power to change how people in organizations build community through collaboration, see themselves in relationship to each other and the organization, and engage in a learning process.

This design-led approach is different from facilitated discussions that use physical props because it is infused with specific design values (see table 1.) which promote a design culture. When incorporated into a comprehensive change process, these design tools for social engagement promise to shift mindsets and spark new behaviors in support of increased collaboration, empathy, experimentation, visualization, integrative thinking and reflection. The net effect here depends upon not any single interaction but rather upon a systematic practice sustained over the long term.

A partnership between designers and OD practitioners in the context of organizational change initiatives is capable of producing valuable new tools and frameworks for conversation and building shared understanding. Designers create context-specific tools to activate participants through more embodied, visual interactions that emphasize learning by doing, making and acting. Organizational development practitioners bring deep, practice-based experience in managing complex change processes and aligning multiple stakeholders at different levels around a strategic vision. They possess a heightened sensitivity to the hidden structures and vibrations within complex social systems, and they understand how to navigate and confront organizational dynamics. Working together, designers and organization development professionals can become a powerful force for shepherding organizations through change processes with the aid of design tools for social engagement.

Figure 5. An Object for Capturing Feedback

Figure 5. An object for capturing feedback (photo credit: Design for Social Impact)

This article originally appeared in OD PRACTITIONER Vol. 47 No. 3 2015, a journal published by the Organization Development Network, and is reprinted here with permission. Special thanks to my colleagues and graduate students from the Design for Social Impact and Industrial Design programs at The University of the Arts, without whose work this article would not have been possible..


Brown, T. (2008, June). Design thinking. Harvard Business Review, 84-92. Retrieved from http://www.ideo.com/images/uploads/thoughts/IDEO_HBR_Design_Thinking.pdf

Buchanan, R. (1992). Wicked problems in design thinking. Design Issues, 8(2),5-21.

Burns, C., Cottam, H., Vanstone, C., & Winhall, J. (2006). RED Paper 02: Transformation design. UK Design Council. Retrieved from http://www.cihm.leeds.ac.uk/document_downloads/REDPAPER02TransformationDesign.pdf

Cross, N. (2011). Design thinking as a form of Intelligence. In S. Stewart (Ed.), Design thinking research symposium, 8 (pp. 99-105). University of Technology Sydney.

Design for Social Impact MDes – The University of the Arts | 1199c Training Fund (n.d.). Retrieved from http://dsi.uarts.edu/featured/1199c-training-fund-2

Design for Social Impact MDes – The University of the Arts | University of Pennsylvania Health System. (n.d.). Retrieved from http://dsi.uarts.edu/featured/university-of-pennsylvania-health-system

Design Thinking… What is That? (2006, March 20). Retrieved from https://www.fastcompany.com/919258/design-thinking-what/

Golsby-Smith, T. (1996). Fourth order design: A practical perspective. Design Issues, 12(1), 5-25.

Hillson, B. (2013). Sustaining organizational culture change (Master’s thesis). The University of the Arts, Philadelphia, PA. Retrieved from http://issuu.com/mid_uarts/docs/hillson_thesis__issuu_

Kolko, J. (2011). Exposing the magic of design: A practitioner’s guide to the methods and theory of synthesis. New York, NY: Oxford University Press.

Lillington, K. (2015, March 12). The man helping IBM rediscover its commitment to a strong design ethos. The Irish Times. Retrieved from https://www.irishtimes.com/business/technology/the-man-helping-ibm-rediscover-its-commitment-to-a-strong-design-ethos-1.2135276

Manzini, E. (2015). Design, when everybody designs: An introduction to design for social innovation. Cambridge, MA: The MIT Press.

Martin, R. L. (2009). The design of business: Why design thinking is the next competitive advantage. Boston, MA: Harvard Business Press.

MICA Social Design (Producer). Robert W Deutsch Visiting Scholar Doug Powell Public Lecture: Social Design: Where Do We Go From Here? [Video file]. Retrieved from https://vimeo.com/88416645

Sanders, E. B.-N., Stappers, P. J. (2008, March). Co-creation and the new landscapes of design. CoDesign: International Journal of CoCreation in Design and the Arts 4(1), 5-18. doi:10.1080/15710880701875068