1. Lunchtime University 10th September 2013 Design for Use

2. The Benefits of Rapid Iteration with End Users Rod Rivers, September 2013

3. The design of a talk Scope and goals Concepts Learning Points Further reading Interaction and Graphics
This talk is about design for use. So, in this spirit, before I started I looked up some tips on the design of good talks. It said …

4. How we should do it

5. What we tend to do

6. How we should do it

7. What we tend to do

8. How we should do it

9. What we tend to do

10. Scope It’s broad Not specifically methodology More psychology Not so much designing the system right, as designing the right system
Well the scope is broad. We are not just talking about the design of say Rio or the web site. We are not just talking about the design of IT systems in CPFT, although I will consider some issues here. Probably the main focus is on the design of systems generally within CPFT including the implied design of systemic behaviours that fall out of the detailed design of some individual systems.
This is not a talk specifically about methodology although it may have some consequences for it.
It is more a talk about psychology, about understanding the psychology of the user, understanding the organization and its culture and understanding how the approach to design might impact on the way the organization goes about its business.
It is not so much about designing the system right, but about designing the right system.

11. Goals Think about our own systems Open up our thinking Make it a bit more fun
The goal is to help us consider our own design and usability issues in our own projects and consider whether and how any of the concepts apply.
Also, the goal is to open up our thinking – to release it from the cage of particular methodologies, to encourage a little innovation and creative thinking – to make the work not only more relevant and productive but also more fun.
Also, let’s make it a bit interactive. I have borrowed from the idea that we might do a few little tasks or games. So here is the first one.

12. Task 1 – What do you do? Write down the project or part of the system you are working on. Don’t all put ‘Rio’ – just your bit Just one (if you work on many)
write down the system or the part of the system you are working on. So ideally I want as many different answers as there are people in the room – don’t just all put Rio. If other people are working on the same system just put the bit you are responsible for. If you are working on two things, just pick the one you would most like to think about.

13. Task 2 – Benefits Write down the main benefit of this project (or part of project) Just one again will do
Before we go on let’s have another simple task. Below what you have already written, can you please write down the main benefit of what you are doing. What difference will it make to the world? What will change as a result of your activity?

14. Let’s see what we have

15. Some Concepts Opportunity Cost Affordance Laddering Follow the money Uncertainty and Risk

16. Task 3 – Who Benefits? Look at your answer to task 2 and ask who gets the benefit Who are you doing this task for? Who’s life will be most directly enhanced? Who are you thinking of when you do it?
and now, let’s just consider who benefits most from what you are doing. Who will benefit from the successful implementation of your project?
This is a tricky one case there could be many beneficiaries – lets hope there are not none. So for this, look hard at your answer to task 2. Who’s life is going to be most enhanced by you doing what you do? This requires measuring benefits so you can see who gets most out of it. Even if you feel that what you are doing is actually meaningless, there is probably somebody that benefits from having you do it. Just write down the first thing that comes into your head about who you feel you are doing this task for.

17. Task 4 – Motivations Why do you do what you do
Task 4 – Motivations Why do you do what you do? Part A – Work Motivations Past B – Personal Motivations
Now let’s look at motivations. Why do you do what you do? Let’s take this in 2 parts. First, the work context and then personal motivation.

18. Task 4A – Work Motivations Look at your answer to task 1 and ask why is this done What does it say in your work instructions? What is the direct work reason you do it?
So, in the work context look at what you do and just ask the question ‘why is this job done?’. What does it contribute?
And then, take that answer and like a small child just ask that question again, and why is that done. This is called laddering. Do it a number of times until you can’t answer the question any more, until you reach a point where there are no other reasons.
Now let’s compare some of these top level answers. I don’t know for sure where this is going, by the way.
So, let’s do it now.
And now let’s compare answers.
Usually this tops out in things like wellbeing (or safety and security) and efficiency.

19. Task 4A – Laddering Write this just above your answer for what you do To ensure projects are on track | - | Manage project reviews

20. Task 4A – More Laddering Carry on asking why and writing the answers above etc. | - | Check project on track | - | Do project review

21. Task 4B – Personal Motivations Look at your answer to task 1 and ask why do you do it What is you own motivation? What directly do you get out of it?
So, now we know what you do, who benefits and why, but now ask yourself why you do it. What is it that is motivating you personally, what do you get out of it?
First, write the first thing that comes into you head. Then ladder up by asking ‘why’ and see what you get.
An interesting aspect of this is if you take any point in the ladder and ask ‘how’ instead of ‘why’, you go down the ladder instead. You may be able to think of many ways in which you can answer the question ‘how’ and these are all alternatives or options as to how you might achieve the goal above. Selecting between these options is another big subject, so let’s not unpack the psychology of decision making today.

22. Task 4B – Personal Laddering Create a ladder upwards for your personal motivations ? | - | Manage project reviews

23. Reflection on tasks Are all our answers aligned
Reflection on tasks Are all our answers aligned? Have we mentioned end users anywhere? Is there a clear, traceable route to end user wellbeing?
It is interesting to reflect on how aligned the answers to questions about befits, who benefits and motivations are. In an ideal world there would be a traceable link between what you do and the benefit it confers on the end users of the system – and what I mean by that is our customers (or as we like to call them service users or patients).
So, ideally, even if your job was something detailed like, say, configuring the ‘legitimate relationships’ module in Rio you would have a clear idea that you were doing this in the best interests of the end user (i.e. to protect their confidentiality and privacy while at the same time facilitating information exchange that would lead to the best treatment). You would be motivated to do the best job you can to benefit the end user and the end user would be the main beneficiary (i.e. not the case manager, the consultant psychologist, the executive board of the Trust or your manager). And if you saw any mismatch (i.e. this may help the GP but it disadvantages the end user) you would be alert to this and use that knowledge to question what you were doing.

24. More on Concepts Value systems (own, manager, organisation, regulators, end user) Stepping in the shoes Users vary (personalisation) User and much else change
One problem with this is that it is often quite difficult to assess what is of real benefit to an end user. There are some techniques to help you do this better, but there is a strong tendency to evaluate benefit in terms of your own or the organizations value system rather than those of the end user.
To understand the end user you really have to know all about them – to step into their shoes and see the world from their perspective. What they regard as a benefit might be quite different (even the opposite) of what you, a doctor or a manager might regard as a benefit. This therapy might keep me calm (benefit to society) but it also makes me put on weight (negative benefit to me).
When I first looked at what this organization does when it receives a new patient into the wards I was genuinely appalled. I had this image of a nice cup of tea and piece of cake while having the opportunity to explain ones story in detail and try to build mechanisms to cope and recover. What I found what that it consisted of a risk management interview, in which the risk was not to the patient, but to the organization if it didn’t keep you safe. This is why the push towards every patient having a comprehensive care plan expressed in their own terms reflecting their own values is so important.
There are also many other issues. Not all users are the same. The website, for example, has over 20 different user types divided into five main clusters. Each user type may want to perform many different tasks. Each individual user may have a rather different conceptual model of what the task involves.

25. More Reflection Opportunity costs Its not sufficient that something is useful It has to be more useful than anything else Who has the big picture?
The trouble is that it is easy to claim that an action is of benefit to end users when it is not. So, for example, people here often claim that they spend a lot of their day form filling and in administration. Well, this is all very useful to the management of the organization. We need to know about, say, risks to patient safety or how many appraisals or mandatory training modules have been completed. But these activities cannot be judged just on their own merit. They have an opportunity cost. This is a term from economics which means that one of the costs of doing something is not being able to do something else – like say, directly caring for the patient.
What seems to happen is that the need to monitor and control activity interferes with its actual performance (it’s a sort of Heisenberg principle applied to work). And the trouble is, there is a pernicious feedback loop. When something goes wrong, people rush in to design systems that make sure it doesn’t happen again in the future. So, there are systems like Datex for reporting. These reports go to managers who think about it and devise policies and procedures and then make it mandatory that staff follow them. Sometimes these policies get as far as being enshrined in legislation and regulation and then filter back down into the operational systems. And all these systems are very good and can be justified in their own right. But who is assessing the opportunity cost? Who is making sure that the whole thing hangs together and that a CPN’s day doesn’t consists of 4 hours form filling and handover procedures, 2 hours travel and just one and a half hours providing care to patients. 25

26. More Reflection - Affordance Capital vs Revenue User vs Developer Design vs Development Planning Vs Implementation
Also, design decisions have affordances and hidden consequences. An ‘affordance’ is the tendency of a particular design to invoke in a user, a particular behaviour. So if you put a handle on a door then people will tend to pull it, but if you put a plate on it, a user will push. Try putting a handle on a door that opens the other way (buy yourself a sandwich, and stand back and watch the consequences). It’s quite difficult to anticipate these affordances without a tight loop between design and use. Design it, try it, re-design it, try it etc.
Unfortunately many of our own systems ‘afford’ bad design behaviour. Take the financial system, for example. It makes a distinction between capital projects and revenue projects. This affords methodologies that separate design from use. It fails to acknowledge that good designs evolve over time. You don’t just design and develop something then push it into ‘Business as Usual’ and forget about it. That is unless you want it to not work very well in the first place and then to quickly become a hindrance as the context of its usage changes (as it inevitably does).
In fact, I would be in favour of throwing away a lot of distinctions like this – capital and revenue, user and developer, design and development, planning and implementation. Some people think that this is not much short of throwing away civilization. But all these distinctions play their part in lengthening the loop between design and use. They can be useful, but really just as tools of thought. As soon as you start building entire systems and methodologies around them you are going down a road towards digging holes and filling them in again just to give people something to do.

27. More Reflection Why methodology
More Reflection Why methodology? Consistency, repeatability, economies of scale Manage complexity, uncertainty and risk 27

28. More Reflection Why not heavy methodology
More Reflection Why not heavy methodology? Chinese whispers Proximity of decision makers to users Control rather than facilitation National programme for IT
Also, this prolonged waterfall process of outline case, options, full business case, PIDs and so on, in my view invites failure by making the process one long game of Chinese whispers, especially as staff change, managers change, technologies change, policies change etc. etc. And then, any crucial decisions are made by management staff that could not be further isolated from users if you tried and not even the project proposers and developers are involved.
As you have probably realized, I’m a bit questioning of some methodologies because they often imposes another set of bureaucratic systems where you start doing things because the system says so rather than because there is a direct and common sense link to user benefits. You only have to consider the write-off of the multi-billion pound national programme for IT to see the dangers.
Methodologies are often introduced to help management stay in control (especially when there’s a lot of complexity and uncertainty). Somebody said on the radio the other day ‘change is the price we pay for democracy’. There have certainly been a lot of changes in CPFT (I’ll resist commenting on whether it’s a democracy!).

29. Another approach? Focus on users Focus on purpose Devolve decisions Guided not ballistic An instant world Co-production Experienced based design
Techniques that increase understanding of purpose and remove the risks of designing unusable systems are co-production and rapid iteration between design and use.
We live in a world of instant data capture and communication, the seven-second video, the text message and the 140 character tweet. The cumbersome methodologies are dinosaurs. They will hang on to the bitter end but it would be kinder to lead them to a comfy retirement reserve, than let them be killed off in a fight for the survival of the fittest.
In co-production you include users in the teams that design and build of the system. And I mean ‘include’ not just ‘consult’ or do user trials or devise use cases. The users are as much part of the team and the decision making process as the people with the development skills. Better still, teach your users to do the development and just facilitate it.

30. Main Messages The user as the main reference point Align your own motivations to the users Take no non-sense (unclear chains) Co-produce Beware hidden systemic effects Iterate rapidly
Put yourself in the shoes of the end user and continuously evaluate what you are doing against that reference point.
Understand your own motivations and work towards aligning them with those of the end user (and not the other way round! i.e. changing the end user to fit what you want – this works in relationships too by the way).
Beware of methodologies. Where the chain of reasoning between what you are doing and what benefits the end user doesn’t hang together in a very clear and straightforward way, don’t be afraid to bring it to the surface and question it. If you don’t understand it then it needs scrutiny.
Use co-production where possible and little reality check techniques, like laddering, can be useful
Understand that how you design your systems has a hidden systemic effect that impacts the activities and culture of the whole organization – consider the affordances and opportunity cost as well as the benefit
Iterate rapidly (whenever you get a chance!)
In short, take no nonsense, understand the user and understand yourself then go with what you believe in.
And, finally, be flexible and don’t take it too seriously - in the words of Groucho Marx – ‘I’ve got my principles,
but if you don’t like those, I’ve got some other ones’.

31. Further Information User Analysis User Outcomes Service User Involvement in Design Experiences-base design Grasping the Nettle Care on Wards

32. Some objection to involving users
Response
Users don’t know what they want
Fast interaction is to facilitate working it out
What about other stakeholder interests (e.g. ATC).
Often already ‘embedded’ in user, but also iterate with other stakeholders too
Users don’t agree with each other
Iteration leads either to agreement or genuine differences that should be addressed
It takes too long – lengthens the process
It cuts out the bureaucracy and goes fast to the right system

33. Task 4B – Work Laddering Activity clearly traceable to (best) end user benefit | - | Manage project reviews

34. Rod Rivers, Lead for Online Services
Online Access to Services, Information and Support
OASIS Web Site Project
Advice and Referral Centre (ARC)
Rod Rivers, Lead for Online Services

35. The Home Page

36. Users Corporate stakeholders People in need of help and support Carers
Professionals
ARC staff

37. The Home Page

38. The Home Page

53.
Provides a single point of access to 260 services:
About ~70 CPFT services
About ~190 third party mental health related services including:
70 online services
120 local and national charities, voluntary organizations and social enterprises

55. Now Live The new CPFT web site – www.cpft.nhs.uk
Went live on 30th August 2012
Anybody with access to the internet 
Supplementary information for health professionals
ARC staff will use site in support of their activities
Advice and Referral Centre (ARC)
Also went live on 30th August 2012
Phone line for single point of access
Initially for GPs / referrers in Peterborough area 

56. Other features More sections – Find help, carers, professional
Multi-media
Further/ related information
Calendar
2nd level menus in blue

59. USPs Personal Local Accessible Integrated Choice

60. Coming Soon Personalisation ARC configuration Service reviews Forums
User content

61. Purpose of GPs Pages Fast access to Metal health information
Referrals into CPFT
‘Referral’ to self-help

69. People in need of help and support
The ‘Markets’
Enhancing wellbeing
Self-help
Primary care
Secondary care
The Goals
Preventing progression
Reducing barriers
Recovery

70. Target user groups – Progression and Recovery
No mental health problems
Mild to moderate problems
Primary Care
(GPs, IAPTs)
Secondary
Care

71. Services Directories
Online services - primarily offered online via the internet. In most cases these services do not have a physical address that you can visit in person. Online services are useful for self help, especially if you prefer to explore these web sites at home or anonymously.
Local and National 3rd party services mainly voluntary organisations, charities, self-help groups and social enterprises. Most have a physical address and most also have web sites that describe their organisations. Local and national services are useful for support and if you are happy to visit these services in person or phone / write to them.
CPFT services NHS services that provide professional help to people with specific mental health problems that cannot easily be addressed by self-help alone.