Well-designed cities can go a long way in supporting the achievement of SDG 3, good health and well-being. When the City of Cape Town was named World Design Capital 2014, it decided to test the service design methodology within one of its busiest, and most comprehensive day clinics, the Ikwhezi Clinic in the Nomzamo township.  Alderman Jean-Pierre Smith, the new head of health services in Cape Town, reveals how the WDC Ikhwezi project has since sparked off a number of service design and creative improvements in the City’s health services.

 

What are some of the key challenges in your city with regards to health care and the promotion of SDG 3, good health and well-being?

The need for access to healthcare services in the City is immense and as a Caring City, we continue to add services to meet those needs. However, the resource-constrained context within which we operate means we are continually challenged to improve the efficiency of meeting the needs of our citizens.

For example, the City of Cape Town provides nurse-based care, with doctor support: nurses are trained according to specific protocols/guidelines and mentored to be able to see about 80% of the clients presenting at the primary health care clinics. Only complicated cases see the doctor. However, the pace of change experienced in the last 10 years with regards to treatment of HIV/AIDS and tuberculosis, including drug-resistant TB, has made it difficult to keep abreast with the necessary nurse training. High staff attrition compounds the problem with constant setbacks in the percentage of clinical staff who received the necessary training.

Image on the left: Colour-coded doors help patients to better navigate their way through the Clinic

Image on the right: Mom and baby care integrated in one-stop shop

On the other hand, the need to rapidly expand access to antiretroviral (ARV) care with limited human resources, necessitated task-shifting to the lowest possible competent staff category: counsellors do the majority of HIV counselling and testing; prep work is done by nursing assistants, professional nurses, clinical nursing practitioners and doctors do the clinical work; and clerical staff capture critical programme data. Task-shifting made it possible to achieve high rates of proficiency, but resulted in programme silos and impacted negatively in the integration of care to the clients who have to see a number of practitioners before they finally get to pick up the drugs from the pharmacy.

 

How do you think design has helped to improve health care for Capetonians? 

To reduce the time spent in the clinic and improve the client experience, service design principles have been key to bring together the various role-players, map out the patients’ flow, identify duplications and unnecessary steps, remove bottlenecks and, most of all, get staff to understand the role each category of staff has in the bigger picture.

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The importance of viewing processes from the point of view of the client has been of crucial importance to the design of future interventions and has moved us away from ‘top-down’ process planning and re-oriented our approach to be more facilitative and ‘ground-up’.

What did the Ikhwezi Clinic project reveal about the importance of design in health care service delivery, accessibility, and patient experience? What were some of the successes and lessons learned? 

As one of our most complex facilities, the work to map out and improve patient flow at Ikhwezi clinic through iterative client-centric processes was instrumental in informing how we rollout improvements in other clinics. The importance of viewing processes from the point of view of the client has been of crucial importance to the design of future interventions and has moved us away from ‘top-down’ process planning and re-oriented our approach to be more facilitative and ‘ground-up’.

Designing processes around empathy has also helped teams within the clinic to really consider how to make process changes that lead to improved patient outcomes rather than being stuck within existing processes that used to frustrate our customers and staff.

As part of WDC 2014, Cape Town used a design methodology to improve the patient experience at one of its busiest clinics, Ikhwezi. The success of this initiative, including a new appointment system, has since been replicated in other health facilities across Cape Town.

Service design principles have been particularly effective at getting individuals (both employees and customers) buy-in when there are service constraints and multiple competing interests, ensuring that such complex challenges are worked on collaboratively and experimentally until an optimal solution is co-developed that can be rolled out – minimizing the risk of failure/discord.

The key to this process for us has been the level of engagement that it has facilitated, allowing staff to experiment and collaboratively develop processes that meet customer needs (and meet our service delivery standards).

How have you replicated the Ikhwezi Clinic outcomes across other public services?

We have embedded customer centricity in our organizational strategy in an effort to further embed this approach. Furthermore, we see the service design culture and mindset as something that we need to embrace as an organization and we are thus trying to push the culture of the organization to embrace tenets of collaboration, innovation and efficiency. We are laying the foundation for continual service improvement.

 

Your city continues to gain momentum in using design to strengthen its health care services, monitoring what works and what does not. Can you tell us a little bit about what the future holds for your city with respect to design-led innovation in health care and other services? How will design continue to make a difference in the lives of Capetonians?

A major project that we hold as perhaps the most significant to improve clients’ experiences with accessing health services is the appointment booking system. This is currently at various phases of implementation at all health facilities in a paper format, but great strides are being made to make it electronic and improve its functionality for both staff and clients.

The rollout city-wide of basic antenatal care (BANC) and post-natal services provides an opportunity to ensure that mom and baby are seen as a pair and provided with integrated care by a single clinician. This means that the mom and baby do not have to make separate appointments on different times or in some cases different days. It ultimately eliminates extra visits to the doctor for both mom and baby.

The path to economic growth and development is enhanced by providing opportunities for women to participate in the wider economy of a country. Fragmented health services for mothers and babies places a burden on women who have to juggle their many roles of mother, wife, homemaker and breadwinner. Where there is a high burden of HIV infection, the drain of numerous visits to the clinic, with long waiting times for the necessary health care, precludes many a woman of looking after themselves and their families properly.

The provision of vertically organized services of immunization, care for sick children, ARV care for the baby separate from the mother’s ARV care, as well as family planning (FP) methods which are provided in another room by a dedicated FP practitioner is a well-known health services’ arrangement that works well for health care providers. In each individual silo staff might excel in their respective areas of expertise. And yet, the result is that mothers find it impossible to keep a multitude of clinic appointments, missing critical stages, only to be labelled as ‘defaulters’ and reprimanded for it.

The City of Cape Town has made a decision to re-design health care services to ensure mothers and babies are seen as a pair, receiving integrated care starting from the time of conception and extending for as long as required. Basic Ante-Natal Care (BANC) services were first rolled out to all City of Cape Town health facilities; Post-Natal care was subsequently made available at all clinics; and finally, efforts are now being made to integrate Mom and child care as ‘one stop shop’.

Amongst other issues the integration of mom and baby care means that during BANC appointments, future moms can be given the baby’s Road to Health Card ahead of time, taught about the importance of loving and talking to the baby in the womb and make sure she is ‘connected’ for extended support. The early follow-up after delivery helps staff pick-up mental health issues and offer support for breastfeeding.

Principles of design methodology are used to design the offering of these services for Mom and baby together in a more cost-effective way to identify and address problems that otherwise might play out negatively in the first thousand days of the life of the child. The well-being of the mother, including the provision of a safe FP method to prevent unintended pregnancies is just as important.

Finally, the development of integrated adult stationary (patient records) to facilitate the work of clinicians, prompting them to surface the history and take necessary action, holds great promise for clients to receive the care they need without being sent from pillar to post. The structured approach also facilitates data collection for audits and for monitoring and evaluation of programmes implementation and outcomes. Again, service design principles involving the full array of role-players have been applied to arrive at a format that is ready to be piloted.

More broadly, in relation to the rest of the City, we are spearheading a re-orientation of our service delivery approach to one that is more customer-centric. We are looking to include citizens more actively in consideration around service delivery and design and ensuring that our primary metrics of delivery are of how well we are meeting customer needs/expectations.

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