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CommuniCare is a healthcare service/systems design project aims to increase the uptake of community care services of breast cancer supportive and survivorship care by providing holistic patient experience and touchpoints of transition and referral service system through empathic and human-centred design interventions from the National Cancer Centre Singapore (NCCS) to the community services for breast cancer survivors (BCS) ongoing primary and post-treatment.

CommuniCare
 

CommuniCare was initiated and conducted during the shift in Singapore's public health sector of survivorship and supportive care provision from a tertiary-care centric model to a shared-care model. The shift was started in the NCCS, where 2/3 of cancer treatments and research are situated, including various pilot programs and service testings.

 

I had the incredible opportunity as the project lead to work with the amazing teams of health clinicians, corporate communications, BCS, service and interior designers, and building developers. We had the wonderful chance to create a holistic service system for BCS, providing a sense of support in each touchpoints of referral and transit process from the NCCS to the community services where interventions introduced would engage, empower and enable BCS throughout their care journey, increase their self-efficacy to adopt an active health-seeking behaviour and the motivation and drive to uptake the essential care services in their community.

ROLE

Service systems design, UX research & strategy, UI Design, Spatial Design, Academic Research, Co-design facilitation, Publication Design.

PROJECT CREDITS

National Cancer Centre of Singapore (NCCS) Supportive and Palliative care Oncologists & Nurses, Corporate Communications team, Building and Program Developers, and Interior Designers.

COMPANY 

National Cancer Centre of Singapore (NCCS)
2021

AWARDS & RECOGNITIONS

Orchard X Cineleisure Exhibition
Faculty of Design Best of 2021

 

LASALLE Creative Entrepreneurial Challenge 2021
Runner-up winner  

The LASALLE Show 2021

Top 8 Research Project Features
 

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Project Background
 

With the advancement of care treatments and improved cure rates, the BCS population is anticipated to increase over the next few decades with no signs of abating. For BCS, they are not entirely cured even with full remission. They face various of psychosocial and physical concerns. A few include anxiety, fear, self-esteem and a negative outlook on life. Therefore supportive and survivorship care is highly important and beneficial. Such care provision has been planned to be conducted in a shared-care model incorporating more of the primary-care sector and community partners. 

3,136

Cases
in 2018

#1 Cancer among Singaporean women. 4,975 cases to be expected by 2040.

100%

*

BCS face psychosocial and physical challenges; affects navigation of daily life

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Shift from tertiary-based survivorship care model to shared-care model.

Prior to the initiation and execution of this project, I embarked on an academic research in 2020 which paper investigated the gaps in the socio-cultural related contributors to the health-seeking behaviours and communication barriers of BCS in respect to the current provision of survivorship care in Singapore's public health sector and their health clinicians. The underlying contributors were found to be an impediment to the shared-care model shift. The research findings then discovered the two main root causes of the problem; BCS health-seeking behaviors towards the care provision and the flaw in the system -both in the front end and the back end in designing for a breast cancer survivorship care service and programs. Therefore in 2021, lead to the collaboration with the National Cancer Centre of Singapore (NCCS), hence, the project CommuniCare.

The "Problem"
 

Survivorship and supportive care is important for Breast Cancer Survivors (BCS) facing psychosocial and physical concerns in their recovery journey. The NCCS has been conducting various upskilling efforts and partnerships with the community services in preparing for the shared-care model shift to provide for this care.

 

However, in Singapore’s multi-cultural context, various socio-cultural factors influence negatively on how BCS health-seeking behaviours, on how they communicate, participate and comply to recommended care services. With the current fragmented and lack of empathic service system in both the frontstage and backstage of the transition and referral process from the NCCS to the community care, the huge shift is at a high risk of low number of uptakes from BCS.

Where
CommuniCare
Stands

 

CommuniCare aims to increase the uptake of community care services of breast cancer supportive care by providing holistic patient experience and touchpoints of transition and referral process through empathic and human-centered design interventions from the NCCS to the community care for BCS ongoing primary and post-treatment. 

 

By introducing a holistic service system, providing a sense of support in each touchpoint of referral and transit in NCCS to community services, Interventions aim to engage, empower and enable BCS throughout each journey, increase self-efficacy to be active in their care and increase the motivation and drive to uptake the essential care services in their community.

Understanding the fragmented backstage and frontstage referral process and the flaw in the current approach of designing a healthcare service program for the survivors, CommuniCare also introduce the design process approaches of;

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Values BCS’ perspectives of needs and preferences

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Holistic, empathic and supportive touchpoints

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Collaborative
Process

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Consider user’s needs & Implementer’s limitations

Project Pathways
& Approach

 

Research & Investigation

Solution

Prototype

Collaborative Problem Solving

Comparison & Testings

Testings

Reiterations

Execution & Implementation

Strategising with the stakeholders, CommuniCare adopts a project pathway that encapsulates the above. The pathway is not linear, where necessary steps needed to be retaken were done accordingly. Throughout the design ideation and process, the following stakeholder groups were involved in various stages of research with the NCCS team and BCS actively involved in co-design processes. Insights were then generated by synthesising raw findings and reviewing existing research and case studies and supplementing it with targeted user research. 

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Archives from the CommuniCare Design Guide Booklet. Click here to view full booklet

CommuniCare proposition of the collaborative work process was initiated when the research findings indicated that there is a tremendous lack of BCS and service designer involved in the process of a healthcare service design in NCCS. This is similarly the case for some other tertiary care in Singapore. Most of the parties involved are the clinicians themselves, the corporate communication and if there is any communication materials needed, it would be with external parties. Therefore, the feedback process is very staggered and distant. CommuniCare sees this opportunity to look into these gaps and approach the collaborative nature of work, ideating with all stakeholders and the involvement of BCS throughout. This allows discovering the gaps of the current system more critically and holistic understanding of BCS' lives and behaviours directly. These provided a more systematic foundation for ideating and prototyping design interventions.

The Research
Scope 

Breast Cancer survivorship care and journey is a multidimensional and multidisciplinary area which systems and services encompass beyond the medical field. CommuniCare's research was conducted in two phases. Phase 1 pivoted on understanding the BCS and their behaviours by investigating the contributors of the underlying personal and socio-culutural factors and Singapore's survivorship care systems. While Phase 2 focused on the tackling the practice of the backstage and frontstage of the survivorship care referral system in NCCS that involves the following areas;


(1) To find out patients' goals and pain points.
(2) To research and propose a new patient journey and flow.
(3) To identify each aforementioned insight and identify the touchpoints to design a more empathic and human-centred touchpoints & solutions.

(4) To provide a new holistic system and service blueprint that would engage, empower, and enable BCS in the front stage and provide a strategic workflow for the back end stakeholders and implementers.

Research
Methods

Both research phases relied on qualitative and quantitative research that includes in-depth and expert interviews, case studies, user testings and collaborative design processes. Lastly, conversation and affinity mapping was done to synthesise the research findings.

 

With various stakeholders involved, various approach towards the stakeholders was taken. In approaching BCS where their survivorship journey is considered by the majority of them as a sensitive topic to be discussed, the interviews and user testings were conducted in a non-formal manner of conversation and question guidelines (sample below) were utilised to keep track of the conversation. For the NCCS teams of clinicians corporate comms and building developers, in long interviews and co-design processes, proposals of drafts and prototypes along with prenstation slides are used as a guideline for sessions to go seamlessly. Most of the sessions were done online due to the COVID-19 pandemic.

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Discussion and ideation process with the NCCS clinicians

Design processes and materials with/for BCS, designer & NCCS teams

The term BCS and Survivors are perceived differently in various settings. NCCS define the term as “anyone who lives with cancer” and targets all BCS who are is able physically to visit the community services. To provide a better and targeted understanding of BCS individuals and preferences, CommuniCare will first solely focus on BCS who are in their current and post-treatment phases and expand the sub-categories of archetypes and profiles in the long run. Each BCS are a unique individual themselves with variety of preferences, needs, and goals. the following are the four classifications of the targeted BCS groups that we designed the service and systems for. Pseudonyms of the BCS were used.

Research Analyses:
BCS "Personas"

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Archives from the CommuniCare Design Guide Booklet. Click here to view the full booklet

Underlying 
Contirbutors

Socio-cultural factors were found to have great influences on people’s health-seeking behaviours, including how patients communicate their symptoms to their health clinicians. Through the research findings, in Singapore's multi-ethnic and multicultural population, there is a conservative bureaucracy and enclosed nature surrounding the discussion of breast cancer coupled with taboo and stigma that would hinder the effectiveness of offered healthcare services and innovations. It is necessary to evaluate the factors that build up these barriers which influence negatively on BCS attitudes towards the care provision and their respective health clinicians. These would also inform the facets necessary to be considered in designing and/or delivering communication and care for BCS.

 

BCS and clinicians were inquired individually regarding the barriers posed and perceived by both groups which uncovered the multifaceted factors. Through their responses, patterns of these contributors emerged and were found to influence one another respectively. The analysis of these contributors is categorized where the majority of the points listed were evident in both groups.

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Patient Journey 
and Insights

With the collaborative design process in phase 2 with the NCCS stakeholders, we looked into the systems and other ongoing/past pilot programs. In regards to the service system we are designing on - the transition and referral process from the NCCS to the community services -It was found that there are no proper systems in place, or in a lack of better word, a non-existing system that would only rely on a mouth-to-mouth referral and recommendation. Analysing past pilot programs for BCS care, the problem lies on the systemic matters -that they put too much focus on instead of the patents themselves -on how to change BCS' perceptions and behaviours towards the recommended care. Thus lacking the empathic approach added with concerns of manpower and resources shortages as it relied heavily on the small group of supportive care nurses.

 

The following are some note archives of the past pilots' analyses that highlight the same exact gaps that CommuniCare is tackling. We found that the top-down approach and no proper service system design processes involved, no matter what kind of program, services or systems were to be done in the future, the underlying root cause of the problem would not be solved if the system do not tap in any interventions that cater to BCS' needs and preferences.

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Archvies of past pilot analyses. Images are partially blurry as some of them are confidential.

Undertaking a different approach, that puts patients' needs and goals first without sacrificing the back end implementers, We created the new and ideal streamlined patient journey for BCS transitioning from NCCS to community services. We also identified in each specific touchpoint of the journey flow, what would be the specific main issue, patient's pain points and goals in each specific key moments. The following map is a part of the design guide booklet series for the NCCS stakeholders. To view the full booklet you can click here

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1) Visiting NCCS

As a starting point, visiting NCCS is the main key moment for BCS that also acts as the motivation and motivator that contributes to the whole journey. BCS visiting NCCS has their own pertaining medical conditions adding to their state of physical and psychological well-being. Nurses and other clinicians do understand that going to cancer centre frequently, in the long run, is not something preferred for majority of BCS. There are already existing negative emotions and perception of them not being cured and the efforts required to go back and forth the clinic. *Pseudonyms are used in this section.

“They [BCS] would think, “I am still going to the clinic, means I am still unwell, I am still sick.”

Nurse Jia Lin, NCCS, on BCS' emotions of going to tertiary-care centres.

“Why am I coming to the [community] care when I have to go back all the way to NCCS to get the medicines?”

Lim Kim San, 58, Stage II BCS , posing Inconvenience going back and forth different locations of NCCS and Community Services altogether.

2) Waiting Area

The waiting area is one of the main space in the NCCS where BCS spend their time in. It is also utilised as a space where nurses would conduct talk-throughs for BCS, especially those who have high distress to discuss their concerns and/or their care plans. However the current space is very cramped, with high seating capacity and very minimal personal space, the area is inconvenient, uncomfortable and inconducive for these talk-throughs. Adding to that, nurses could not take BCS to a different (available) room/space due to the concern of BCS' appointment queue number visibility.

“The waiting area is the main space and opportunity to go and catch BCS. We don’t usually bring them away because they want to see their queue number.”

Nurse Pei Ling, NCCS, on BCS who comments on NCCS' current waiting area.

I always dread the moment, waiting for my consultation, will I be okay? [...] I need some space to gather my thoughts”

Lina Sujono, 55, Stage II BCS on waiting for her test results.

3) Talk-throughs

Talk-throughs is one of the main form of a supportive care which has numbers of contributors and stakeholders involved -and could also be influenced by the physical space of the waiting area itself. Communication is the main component of cancer care, whether it is an exchange of information or as a social support mechanism.

 

Currently these talk-throughs are mainly conducted by a small group of supportive care nurses who would approach BCS when they are found to have a high distress form the screening. However, there are layers of contributors, especially the socio-cultural context that influence how BCS communicate about their symptoms, challenges and topics surrounding the disease.

One of the important needs of BCS are information and well-informed suggestion on their condition, especially in coping with their treatment. Throughout the primary research, there have been numerous suggestions gathered to have a fellow BCS befriender in NCCS clinician centric system as BCS feel that suggestions are coming from someone who are going through the same journey or treatment as them.

“I am fine, I am perfectly fine there is nothing wrong with me [..] is it just your job to talk to me?”

Nurse Lee, NCCS, on BCS comments she encountered.

““I have Breast Cancer” that itself is already a taboo [...] The symptoms of BC is not similar to a regular cough or flu, it is harder to articulate.”

Mdm. Yueng, 71, Stage II BCS and retired clinician.

“Of course we want to be as holistic as possible, talk a bit more [with BCS], but there is not enough time to do so. Perhaps could we introduce BCS "buddy system"?”

NCCS clinicians, on the limited time and manpower available in providing talk-thorughs and patient-centered care.

“I was diagnosed at 19 and introduced to a survivor who did the same treatment and therapy. It felt less lonely. [..] With the person who's going through the same thing, they would understand me -each other, better.”

Alice Leong, 20, Stage I BCS who befriended a fellow BCS in the clinic.

4) Recs and Refs

When recommending or making formal referrals from NCCS to the community services, the previously discussed key moments affect this particular point of introducing the community partners. Currently NCCS relies heavily on verbal communication and just plan to provide a list of form containing the community services with no tangible extended touchpoint to learn more about the care they would be provided. However majority of BCS are either unaware of the community services, has very ow motivation and interest to go, or both. These are one of the main impediments to the shift.

“If the care is not perceived as useful by them [BCS], they are less likely to comply”

Oncologist Ong, NCCS, on BCS compliance to recommended care.

“Currently, we only have the information compiled. We plan to just give a printed list and have them on our current website.”

Nurse Jia Lin, NCCS, on the current information and resources "available".

5) Back Home and 6) To Community

BCS most likely proceed to go back home after their visit to NCCS. After being introduced do the community services or when referral is made, it is unlikely for them to go immediately. This is one an important key moment where the touchpoints should be “active” in not only to remind or re-inform but to "nudge" them. As most of the times BCS would put they received in NCCS about the services in the back of their mind or forget about it, especially those who do not think that going to community services would be any useful to them.

The end of the journey is affected by how well the previous key moments are being con- ducted, delivered and received. At this end of the journey, the main concern is the actual motivation and drive to get BCS to visit these services as they would opt out last minute to do a first visit. The other concern in the back end is the inability to obtain live data from the community services.

“I think after we introduce the services, they would go back home, some might look them up, some might forget about it.”

NCCS Clinicians, on BCS tendency of low compliance, motivation and drive.

“When we recommend or make a referral to the community services, usually BCS will opt out and they won’t go.”

Oncologist Young, on BCS tendency of low compliance, motivation and drive.

“We are unable to “track” who attended the services. [..] We all have separate back ends.”

Nurse Lee, NCCS, on BCS who commented on data sharing between NCCS and community services

The Solutions:
New Patient Journey 
& Interventions

Through the breakdowns analyses of the previous journey and insights map, we mapped out the interventions to be done in each of the specific touchpoints with 4 mains "solutions"; Furniture design and spatial configurations, a BCS befriender volunteer system, NCCS website page UI/UX design and data collecting system. 

With the right combination of people, spaces and enablers, CommuniCare's interventions produced are driven by the objective of; how can we provide a more empathetic and human-centred patient experience and touchpoints and therefore provide a holistic service system -that would engage, empower and enable BCS at every step of their referral and transit journey to motivate and drive them to attend the recommended and referred community care services taking charge of their care and themselves in transitioning back to their lives. All interventions and design concepts are strategised for their feasibility and viability in respect to the time, cost, resource and manpower, especially with the new NCCS building in 2022.

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Service Blueprint

The service blueprints chart the various touchpoints and interactions that occur throughout the key moments in NCCS that covers the main peri-service period. Each key moments deals with a different set of service touchpoints, or elements, such as people, digital devices, print materials and places. We have highlighted particular points within these blueprints of the particular stakeholders’ actions prominently involved in the frontage and backstage, or both stages of the key moments. The following blueprint is the latest iterations and more of the stakeholders and enablers are to be included in the long run.

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Furniture
Design & Spatial
Configurations

The architecture and spatial related elements in a tertiary care facilities, specifically in NCCS affects patients emotional and wellbeing indirectly. Through site analysis and case studies borrowing frameworks of biophilic and wellness design, CommnuniCare introduces a furniture design of the sitting space of the waiting area along with the spatial configurations that highlight the exposure and connectivity of nature and materials that caters for privacy, convenience and patients' wellness.

In each of the interventions, a sub mini-booklet from the main design guidebooklet will also be introduced that includes the overview of the design considerations behind the proposed interventions along with the stakeholders' comments and inputs. The following would provide a more in-depth rationale and behind the process of the design decisions from the elements, layouts, configurations, and further considerations.

Furniture and Spatial mini booklet

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Furniture and Spatial mini booklet

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Furniture and Spatial mini booklet

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Furniture and Spatial mini booklet

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BCS Befriender
Volunteer

In conducting talk-throughs, we introduce a BCS befriender system. We found that survivors stories and presence from a BCS befriender could promote a positive impact for BCS which conversation would also act as a social support. We found that the BCS are more likely to comply to the other BCS or cancer survivors' recommendation as they feel that it is from someone that has gone through a similar experience and journey as them so they would understand each others' emotions well, or better than health clinicians. 

The following are the "steps" proposed to introduce the befriender. Currently, there are already existing trainings and upskilling efforts with the community partners to care for these BCS that would be referred from NCCS. With that opportunity, we propose to train these BCS volunteer alongside the community partners session in regards to strategizing the cost and manpower. When a separate training session required it would not be necessary to conduct a new program and it would only require 1 - 2 current clinicians to do so. 

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“Recruiting” The Volunteers

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Volunteer’sTraining

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Befriender to Service

In considerations of the various BCS needs and conditions, volunteers along with 1 - 2 supportive care nurses are to be actively stationed in the waiting area and secondary locations of the patient education centre and outpatient clinic. With the considerations of the various BCS conditions and needs, the volunteers would not be stationed alone. A supportive care nurse and/or a social worker would also be present should the situation/ BCS conditions call for a professional.

Befriender and Data Collecting System Booklet

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Befriender and Data Collecting System Booklet

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Befriender and Data Collecting System Booklet

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Befriender and Data Collecting System Booklet

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NCCS Website
Page Interface &
Experience design 

The NCCS website is one of the main sources of cancer-related information for BCS. The current website is deemed to be very text-heavy and lacks engagement. CommuniCare introduces a new framework for the user interface and experience design of the community services page highlighting features that highlight the use of empathic visuals, map and filter search and survivors’ stories, providing engaging and informative content.

Drawing various case studies of medical websites "best practices", in terms of the UI, there are many references available, however, for the overall experience and content specific to the context we are designing for, we should come out with our own framework and guidelines for the NCCS' corporate communications, in the long run, to rely upon.

 

Providing a new framework and design for an existing government based website, sure came with various restrictions and limitations to what kind of experience in the interface we want to introduce and how much we are actually able to do so -and especially, with the already existing layers and layers of information in the menus. Through intensive segmentation of information, prioritisation of categories and thorough planning towards the execution -after various iterations and prototypes, the following is the latest version of the NCCS' community services website page design. Following that, the website walkthrough for desktop and web formats and the design booklet.

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UI Design Booklet and Walkthrough

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UI Design Booklet and Walkthrough

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UI Design Booklet and Walkthrough

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UI Design Booklet and Walkthrough

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Data Collecting
System

In enclosing the loop of the whole system, NCCS would need a measurable outcome would be the numbers and the actions taken pre and post such shown. In the current system, NCCS is unable to keep track or gather specific data on the numbers of uptakes of BCS who attend or are absent from their recommended community services. Whereas community services would also be uninformed of the individuals and their data who are referred from NCCS.

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NCCS: Input first
four sets of Data

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Community Service(s): Update Data snd Status

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Befriender to Service

In catering for the document and data live sharing between two different back end systems, outsourcing or creating a new platform or cloud that would enable this live sharing would not only require much longer time, back ends and the exorbitant cost. Through careful consideration, CommuniCare proposed the excel sheet or a similar platform that would allow this convenience with low cost and manpower. The latest discussion was the concern of how much data should and could be shared between two parties as it involves the BCS personal information. Nonetheless, this particular prototype allowed both parties to have an idea of what would be possible and if such or similar data sharing could be executed.

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Design Guide
Booklets & Maps

With various groups of stakeholders involved, a design guide booklet was provided. They contain all of the overview of the background research findings, process, findings, inputs and comments from each stakeholders groups and design considerations whereas the sub-mini booklets contain similar information that would specifically address the design "solutions" and their own respective components -which some of them you have previewed in each of the furniture and spatial, befriender service, website design and the data collecting interventions. 

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The guidebook is designed in a way of a binder, to allow each of the different categories of information -as separate parts to be customizable and adjustable according to each respective stakeholders' needs. As the entire content is required to take on the project, there are also specific sections -especially the sub-min booklets that would cater directly for the implementers and stakeholders involved so that can take out what they need, to write notes on, et cetera depending on who is working for what. Click here to request fo the main Design Guide Booklet.

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Previews of the main design Guide Booklet.

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In Retrospective
/Afterwords

By the time this paragraph is written, CommuniCare would be under the process of execution stage and iterations of the design interventions are being done. Coming this far with such project, being honoured and grateful are a complete understatement. It was truly a wonderful opportunity not only for a design research project but for the amazing individuals that I had the chance to work alongside with and for, especially the health clinicians and BCS themselves.

 

There were way too many times that conversations with them had me reflect myself life and my practice that could contribute to improving the dimensions in the healthcare field. Not to mention that very moment when the BCS sent their gratitudes and how they are looking forward to seeing them in place -cue tears of joy. It was heartening to see that a huge tertiary care like NCCS, genuinely invested and open to various ideas and interventions. It was a very remarkable experience and as a team, we got to discover so much more by undertaking an active collaborative nature of work, something that was rarely done in-house.

 

The project started and ended accomplishing the mentioned goals and objectives, but what made me very content is what we managed to do beyond that -sparked the conversation that had the NCCS internals relooked into the way things are being done and how systems and programs would be created in the long run -and also having all the clinicians now interested in UI and design. This was truly very exciting and rewarding to see how CommuniCare could do beyond itself as a service system. If you would like to know more about CommuniCare or have any interest in exchanging ideas and inputs, by all means, do feel free to contact me here