Vitamin Lab: How to Take Citizen Responsiveness and Integrity in Health Services to the Next Level

The innovation was developed to tackle the problem of corruption in the Lithuanian healthcare sector. We conducted a Vitamin Lab experiment to find out if the change of the clinic’s environment indirectly affects the behaviour of patients, how it can influence their attitudes towards the clinic, increase transparency and reduce bribery. To our knowledge, it was one of the first initiatives to use this type of measured social design interventions in the context of healthcare sector corruption.

Innovation Summary

Innovation Overview

The problem: Over 50 per cent of Lithuania’s population believe that the healthcare sector is corrupt. 2 out of 5 Lithuanians admit to having paid bribes at the national level healthcare institutions over the period of five years, what makes the healthcare sector the most corrupt public sector in Lithuania. Compared to the EU level, Lithuania has the second highest percentage of bribery at healthcare institutions. While the problem of corruption is attracting increasing attention in the public domain, there has been no firmly demonstrated interest from the policy-shapers to change it, citizens do not have a sufficient sense of empowerment to demand better, more accountable services and the motivation of doctors to initiate change has remained unsupported by systemic political will.

An innovative solution: Given the lack of progress in tackling healthcare corruption through conventional instruments, we developed a bottom-up ambient accountability initiative – Vitamin Lab - to create good case examples and examine the potential of a broader range of innovative citizen-centric mechanisms and their potential to change expectations and relations between customers and service providers, to give more salience to values of professional integrity and work towards empowering patients to make themselves and their feedback heard.

Vitamin Lab is an initiative which features an interactive installation that we created together with the community of Lazdynai Outpatient Clinic (our partners in this initiative) and installed it in the clinic’s waiting area. The volunteers were actively inviting patients to evaluate the quality of services they received that day with the help of installation. Patients were given five evaluation balls, or “vitamins”, and asked to allocate them to one or several of the evaluation categories: (1) Thank you, (2) Service was pleasant, (3) I did not like it, (4) The procedures were clear, (5) I would recommend this clinic to others. Patients were also offered to leave a more detailed written feedback in a Vitamin Lab’s suggestion box.

Qualitative and quantitative research methods were used to assess the importance of feedback and overall success of the initiative: a survey of patients (representative survey, proportional quota sampling, two waves: N = 416, N = 380, total sample size N = 776); in-depth interviews with the polyclinic’s personnel of the Lazdynai Polyclinic; a focus group with Vitamin Lab volunteers; and a focus group with patients of the Clinic.

Goals of this experiment: (1) Better understand the criteria by which patients evaluate the healthcare services; (2) understand how giving patients the opportunity to give feedback impacts their satisfaction with the services they receive; (3) improve patients’ satisfaction of the services they receive; (4) increase patients’ sense of empowerment and demand for good service as well as the salience of values of integrity and service quality in the clinic’s environment; (4) understand how such initiatives contribute to the change of patients’ behaviour and their attitudes towards corruption in healthcare.

Results: The Vitamin Lab experiment provided an opportunity to gain a deeper understanding of doctor–patient relationships and how things actually work at the polyclinic. Thus, as the first initiative of this kind in Lithuania and, to our knowledge, one of the first to use this type of measured social design interventions in the context of healthcare sector corruption, it provided valuable insights into both the healthcare sector in the country and the potential of such interventions and allowed us to have a stronger connection to our stakeholders.

Our main insights from this initiative are as follows: (1) patients who believe that gifts and informal payments do not help to get better services were much more likely to recommend the clinic to others; (2) patients who participated in the ‘Vitamin Lab’ were less likely to believe that unofficial gift-giving or giving money or any other material reward helped them to receive better treatment in the Lazdynai Polyclinic; (3) the possibility to leave a feedback contributes to the better evaluation of the services provided. Patients who participated in the Vitamin Lab were more positive about the services in Lazdynai Outpatient clinic (40.6 (Net Promoter Score) compared to 26.4 (the overall score)).

Innovation Description

What Makes Your Project Innovative?

Our project is innovative in approach, intervention design and implementation. First, we adopted a bottom-up, social design approach, in order to understand the existing culture in healthcare institutions from ‘the practitioners and clients point of view’ through stakeholder workshops and use of participatory design and applied theatre. This led us to co-design and create change through a unique, yet very simple and engaging ambient feedback mechanism that empowers patients and makes feedback highly salient in the clinical arena to all involved. The approach is unique in marrying behavioural insights with TI’s innovative tactic of “ambient accountability” (http://ambient-accountability.org/what) – using creative interventions to promote integrity in the very places and situations where it is challenged. Vitamin lab was the first initiative of this kind in Lithuania and, to our knowledge, a first in the world to use ambient feedback and social design in healthcare corruption.

What is the current status of your innovation?

The Vitamin Lab experiment helped to showcase the importance of small victories – that healthcare institutions need to adapt a measured approach in order to change the status quo and to take in the patients’ feedback. As a result of this initiative, Vilnius city municipality is currently planning a pilot initiative – to carry out representative patients’ surveys in all the public healthcare institutions in the city and rank them based on the results. In addition, other healthcare institutions started thinking about smaller measured initiatives in their environments.

Innovation Development

Collaborations & Partnerships

(1) Lazdynai Outpatient Clinic – main partner;

(2) patients of the clinic – intervention participants; valuable feedback on quality of service of the clinic;

(3) medical community of the clinic – contribution to the design of the intervention;

(4) social designers – application of social design methods in public healthcare institution;

(5) Transparency International Secretariat – research and methodological support;

(6) volunteers – collection of patients’ feedback.

Users, Stakeholders & Beneficiaries

(1) citizens – more willing to recommend clinic; changed perception of entitlements;

(2) doctors – more polite, value-aware to patients and each other;

(3) clinic administration – increased knowledge of service perks/flaws; useful insights for its organizational management;

(4) other healthcare institutions – presented with easily applied tools to increase the service quality;

(5) Vilnius City Municipality – inspired by intervention to consider broader feedback systems in healthcare.

Innovation Reflections

Results, Outcomes & Impacts

It is a first proof of concept that strategic social ambient design interventions can set into motion positive dynamics of change. Simple visible feedback system can rewire the social dynamics, sense of entitlement, trust and expectations.
To measure impact more systematically we carried out: a baseline and ex-post patient surveys (n=416 and n=380), focus groups, interviews, engagement tracking. After the intervention:

(1) patients were more likely to recommend the clinic to friends (rise in net promoter score);

(2) doctors and patients perceive less gift giving and soliciting.

Quotes from stakeholder interviews: “Why I like this system is that when everyone is in a hurry, running, you can very quickly and easily evaluate the service, and don’t need to write or fill out anything.” (patient, male, 76)

“As time went by there were some constant patients who were coming probably… every week. And they were saying: ‘Give me those vitamins, I’ll evaluate the service.’ (volunteer, female, 24)

Challenges and Failures

(1) While we had the buy-in from the administration, it took us more time than expected to get the support from the medical community of the clinic;

(2) we experienced that it can be quite difficult to convince the polyclinic’s community that social design methods can be useful, as they were perceived as overly creative and abstract for the medical personnel not used to such interventions;

(3) we encountered the lack of willingness of the medical personnel and doctors to engage as they chose to isolate themselves from exercises they believe were aimed at changing their everyday routines. In order to address these issues, it was important for us to form a team of experts well in advance and to develop a map of possible risks and their mitigation plans and to act when such risks arise;

(4) last but not least, we hoped to be able to change the behaviour of patients with this intervention, but we managed to change only their attitudes.

Conditions for Success

(1) Leadership and involvement from the top management of the clinic - we started communication with various healthcare sector institutions in Lithuania, however, only managed to build a stronger relationship with Lazdynai Outpatient Clinic;

(2) Human resources - feedback collection requires constant communication with patients; in addition, we put a lot of effort to keep constant communication with the healthcare institutions interested in testing transparency initiatives in their environments, including communication with the management of the Lazdynai Outpatient Clinic;

(3) Personal values and motivation – high level of engagement of medical community in the initiative strongly contributes to its successful implementation.

Replication

The aim of the innovation was never to replicate it but rather to ensure that its DNA is adopted and replicated by other institutions in the country. The initiative gathered a lot of media attention, was widely discussed in the sector and received an award for the best anti-corruption initiative of the year from the Ministry of Health. Last but not least, it encouraged the Vilnius City Municipality to initiate the ranking of the healthcare institutions based on the feedback of service delivery by the patients, inspired the Ministry of Health to set more concrete anticorruption goals and laid first stones for the creation of culture of good case examples in healthcare.

Lessons Learned

(1) It is essential to continuously keep in mind, manage and adjust the expectations of various actors involved in the initiative – it was sometimes challenging and time-consuming to ensure that the activities agreed on were understood in the same manner;
(2) Implementation of such pilot transparency initiatives requires high level of engagement and buy-in of top management of the institution. Moreover, the topic of corruption is very sensitive to the medical personnel and administration of healthcare institutions. Thus, it might take time to identify institutions that want to create change and be good case examples;
(3) It was essential to ensure that such initiatives are measured in a representative manner. The engagement of patients into evaluation of service in the Vitamin Lab was not the goal itself – it was the visual installation that allowed us to receive so much attention for this topic of service quality and contributed to our advocacy goals. The most important part was surveying the patients before and after the Vitamin Lab – this allowed us to measure our involvement and its success / failures;
(4) For our advocacy goals it was important to keep the constant communication with different stakeholders working in the sector (other healthcare institutions, municipality, Ministry of Health, among others). This allowed us to present the approach of small measured interventions in a better manner and create a community of institutions interested in implementation of similar initiatives in the future.