Stakeholders & Beneficiaries

Stakeholders and Beneficiaries include:
  • Fundación Alas and the Special Employment Center Trefemo
  • The families that support the Foundation
  • The disabled elderly supported by the Foundation
  • The regional government of the Comunidad de Madrid (Spain)

Co-creation process

The content of the participation process included three related innovation elements:
  • The services model. This affects the facilities and types of services the elderly demand. But it also affects the type of professionals involved in providing the services. Finally, the measurement of the relevance and impact of the services is subject of review.
  • The facilities’ design. Residences need adaptation, but also the Foundation must develop new facilities to train and fulfil the needs of ageing disabled.
  • The relationships with other agents. If the earlier two might be related to services innovation, this concerns the processes and how the Foundation launches and consolidates new relationships with different public and private agents to help elderly sustain themselves and fulfil their rights to autonomy and proper care.

Digital Transformation Process

No digital transformation process involved.

Results, Outcomes & Impacts

The ageing project of Fundación Alas is centered in solving wicked problems associated with the longer life-expectancy of people with disabilities (Plena inclusión, 2014) thanks to the improvement on their life conditions and treatments. Far from technological, the types of social innovations the foundation designs and executes are related to a public function that public agents in Madrid (Spain) have traditionally left to private agents. Indeed, at least in Madrid, the public agents have failed providing adequate services to this community and currently acts as mere funder of private initiatives – mostly supported through conventional tenders. The effectiveness of the intervention strategies for elderly with intellectual disabilities depends on the ability of the technical teams to develop and communicate clearly the plans to other professionals (Morgan, 1990; Shaddock et al., 1986 in Novell, et al., 2008), but also on the capacity, training and motivation of professionals who have the direct responsibility to carry them out (Aylward, Schloss , Alper and Green, 1995 in Novell, et al., 2008), as well as the coordination between all of them.

Challenges & Bottlenecks

Dimension: Physical fitness

  • Lack of health care standards
  • Communication and identification difficulties of pain threshold
  • Participation in the promotion and living a healthy lifestyle
  • Lack of specific resources and standardised protocols for the evaluation of elderly with   intellectual disabilities
  • Insufficient training of socio-health professionals in ageing issues and intellectual   disabilities
  • Insufficient physical therapy

Dimension: Emotional well-being

  • Integration of the information from the field of dual diagnosis[1] and the gerontology   area[2]
  • Environmental situations having a negative impact on the adaptive abilities of elderly or   could raise behavioural problems or stress
  • Training professionals in ​​ageing and dual diagnosis

Dimension: Material well-being

  • Adaptation to the needs of elderly with intellectual disabilities
  • Less opportunities to participate in meaningful leisure activities, less stimulating   environments, lack of staff preparation and relationship difficulties between individuals
  • Lack of experiences with the rest of the ageing population
  • Segregated and expensive environments
  • Existing geriatric or gerontological intervention models are scarce and are not easily   transferable to services
  • Decreased productivity associated with ageing, difficulty to make personal and social   adjustments beyond the 50
  • Few work or occupational itineraries to support elderly with this condition
  • Pension plans different to those available for those without disabilities
  • Lack of assessments due to disability and ageing to maximise compensation when   leaving   work activity

Dimension: Human Rights

  • Physical access
  • Access to information
  • Disability recognition associated with ageing
  • Right to decide where and with whom to live
  • Right to health, training and rehabilitation
  • Barriers to keeping an adequate standard of living and social protection
  • Right to develop and keep plans and goals

Dimension: Self determination

  • Lack of information necessary to identify or recognise abuses
  • Transition to retirement getting actively involved in self-care

Dimension: Social inclusion

  • Opportunities to participate actively in their environment
  • Lack of relevant social goals and aspirations
  • Greater contact with people without disabilities and greater autonomy
  • Lack of promotion of the inclusion of the elder with intellectual disability by the support  professionals
  • Ageing of the main carers
  • Lack of coherence in the implementation of an inclusive model
  • Shortage of personnel

Dimension: Interpersonal relationships

  • Continuous changes of professionals
  • Housing size
  • Physical and social barriers
  • Long stories of institutionalisation and change of services that make it impossible to   consolidate a social network
  • Behavioural problems
  • Adaptive and communication skills

Dimension: Personal development

  • Feeling of ‘disconnection’ with the activities carried out in earlier stages
  • Favouring free-time of their main carers
  • Lack of a process of active ageing
  • Lack of services and opportunities that promote rest, fun and personal development
[1] For example, to know the most frequent psychiatric conditions in the population with ID or specific etiologies that present a higher risk of certain types of mental illness. [2] Identification of which behavioural and psychological changes are associated to the overall ageing process.

Transferability & Replicability

The institutional needs and problems detected in the main services that might affect the project of Fundación Alas are summarised below (Novell, et al., 2008):

Services of homes-residence / supervised homes

Personnel ratios are insufficient, both in residential homes and in homes, when it comes to addressing needs arising from cognitive deficits, behavioural issues and the functional deficits associated with ageing.

Occupational Centres

The ageing process generates continuous adaptation needs that pose an opportunity for the innovation of these services. Most generally, personnel in the occupational centres are not well prepared to carry out the work of Psycho-geriatric Day Centres – e.g., they are not provided with physiotherapy services. These centres usually lack transition services from the world of work towards a compatible satisfactory activity able to meet the needs of people who cannot continue in Special Employment Centre but still can work and get paid and that enhances their skills.

Leisure and educational activities

Elderly with intellectual disabilities need enough and varied social activities, adjusted to their age, to choose from according to preferences and accessibility. Enjoying free time and leisure is one of the most rewarding activities and making them accessible is a good indicator of the quality of a service. The elder with disability has motor and cognitive difficulties to self-organise and, depending on the level of disability, also to enjoy leisure. Promoting adapted leisure for elderly would benefit them normalising activities and improving adaptive behaviours, socialisation, fun and distraction, and quality of life.

Individual level

The need to enhance their self-esteem and personal growth, fighting loneliness; the need of full social acceptance; and the need to make decisions about aspects of one’s life in the most similar way possible to people without disabilities.

Success Factors

Dimension: Physical fitness

  • Sleep, food, activities of daily living
  • Health (physical and mental), health care and access to socio-health services (including technical aids)

Dimension: Emotional well-being

  • Community environments, ordinary or supported employment, significant learning opportunities, absence of problems social or emotional behaviour and support
  • Depression and anxiety, stressors – social exclusion, stigmatisation or lack of social support
  • Healthy lifestyle and food, access to valued activities, health and well-being in the housing environment, adequate emotional response to separation or death of parents

Dimension: Material well-being

  • Economic status (i.e., having enough income to buy what one needs or likes), employment (i.e., having decent work and an adequate working environment), or housing (i.e., having a comfortable home where one feels comfortable)
  • Adequate standard of living
  • Social protection
  • Searching, getting, keeping the employment and having the possibility of returning to it
  • Having the right to choose where and with whom to live

Dimension: Human rights

  • Rights that may be violated at ageing
  • Proposals to empower disabled elderly to educate them to self-manage their lives and defend their rights

Dimension: Self-determination

  • Autonomy or personal control self-regulation or setting own goals and values
  • Training or psychological competence
  • Self-realisation or own elections

Dimension: Social inclusion

  • Active participation of the elderly in their community
  • Residence or housing options that favour social inclusion during ageing

Dimension: Interpersonal relationships

  • Natural supports: significant relationships with family and friends
  • Interpersonal relationships through leisure experiences integrated into the community
  • Collaboration with community services belonging to the network of services for the elderly
  • Interpersonal relationships (friends, partners): emotional, sexual and social

Dimension: Personal development

  • Education, personal competence, performance, functional skills
  • Use of support technology and other alternative communication systems

Lessons learned

This case presents the collaboration process of a private institution with users and their families to provide a public service that is not properly covered by the public sector. It answers a pressing concern of the families and the elderly with disabilities, as this latter group has become a relevant part of the total disabled population. This is not the normal case of a PSINSI, as the public agent is just one of the actors involved by the initiating agents, and mostly covers what relates to the overarching legal or normative framework of the caring for the ageing disabled people. Besides those differences with other social innovation cases, we appreciate similarities that even in the absence of a strong public actor are well covered by the PSINSI theoretical framework. This is relevant as it may indicate that the focus on the social innovation aspect might drive agents, independent of their ascription, to form similar types of networks.

Stakeholders & Beneficiaries

Apart from PricewaterhouseCoopers, beneficiaries include public administrations involved in specific projects such as the Lombardy Region.  

Co-creation process

Uptake of co-creation by private companies is a relatively recent trend, spurred by increased connectivity, technological innovation, and prioritization of user experiences. A recent report from Hitachi Europe found that “58 per cent of businesses have piloted co-creation projects to help them innovate.” More rapid communication between customers and service providers has altered the typical business relationship and thus PwC Experience Centers are becoming critical for facilitating co-creation and producing viable solutions for public sector clients. At the Experience Centers, PwC builds business approaches and methodologies based on their BXT mentality – which recognizes the interconnectedness of Business, Experience, and Technology. It places the human experience at the center of business and technological transformation – ultimately drawing on multiple perspectives and disciplines in development processes. Summarily, the BXT mindset evaluates proposed solutions holistically and stresses the importance of collaborative approaches, building around questions such as; is the solution useable? Is the solution useful? Does the solution work? The Centers’ application of a BXT-minded Service Design for Growth model and its associated co-creation processes help PwC remain adaptable and adjust services to meet specific client demands. The Service Design for Growth model is comprised of four key stages: 1) Exploration, 2) Strategy, 3) Co-Creation, and 4) Growth and focuses on impact and growth delivery. For each design stage, the PwC team introduces exercises to gain clearer understanding, define the service through synthesis of research, generate solutions, and transpose the principles of open-innovation and collaboration in clients’ everyday business. However, different from the sequential and rigid Stage-Gate approach, the process remains Agile in design and replicates the Design>Test>Iterate steps until outcomes are approved by all actors. A final ‘rapid prototype’ is the expected output, which PwC underlines as “cheaply, easily, and quickly changeable.” This method is user-oriented – meaning it is human centric rather than a top-down process – and Co-Creation sessions allow PwC staff to bring together stakeholders in product/service conceptualization to secure equal investment and widespread of the project. PwC also importantly valorizes incremental innovation, focusing on the small deliverables and touch points throughout the design process. At the Experience Centers, PwC teams move clients through the co-creation process that consists of two pre-project phases, Discovery and Session Design, then the Co-Creation Session itself, and lastly is followed by two post-session activities, De-brief and Deliverable Realization. Co-creation sessions can last anywhere from 1-5 days, depending on the client’s request, and are customized to meet specified objectives. The flexible and iterative nature of the co-creation methodologies at the Centers also allows for bi-directional learning. PwC benefits from leading co-creation sessions by refining their own approaches and learning what works with clients and clients revise their own business models to match consumer demands. Applying co-creation approaches brings new knowledge to the firm while also attracting forward thinking clientele. To better understand the specific exercises used in each design stage, we will analyze the use of co-creation sessions and Design Thinking by the PwC Experience Center in Milan, Italy in the Portal for the Lombardy Region project. In July, the PwC Milan Experience Center hosted a collective group including representatives from Regione Lombardia, business and test users, service managers, and other relevant administrative personnel. The participants were selected based on their wide range of backgrounds and intentionally included portal end-users. From the beginning, the co-creation session objective was clearly defined and the following goal was shared with participants: How can we help the project back office (Lombardy Municipality administrators) to operate smoothly to support users in a simple and immediate accession of the project? PwC staff then provided an overview of Design Thinking methodologies and the Design Sprint approach, which aim to promote a multidisciplinary vision, are human-centric, and ultimately deliver solutions in a time efficient manner. PwC staff divided the group into two sub groups, the citizens and the firm, and the groups were given a secret task that involved the user portal in order to initiate the service road mapping exercises. In the mapping process, there was emphasis placed on asking ‘why’ behind each problem solving statement to help uncover what the root issues were for the service providers and consumers. Giving each group a persona with specific user characteristics helped participants develop mutual understanding for the needs of the user portal and the challenges faced by firms developing the products. Further, PwC bases proto-personas used in the exercises on real data and market research to guarantee that the alignment in communication resulting from the session is applicable in a real world setting. After discussing the frustrations and needs of each persona in their groups, participants played a word association game where they could role-play and discover their overlapping concerns. Next, in the analysis phase, participants identified the various touch points for the portal services and discovered where there were issues within the service delivery model. Lastly, they worked together to generate solutions for how to enhance communication between stakeholders and improve the operational flow from a “What I Need From You” perspective. Overall, in the Lombardy Portal use case, the Experience Center’s co-creation session was instrumental for bringing together stakeholders using an all-inclusive approach and for creating an innovative, user-friendly service/product delivery model. The final output was a new ready-to-use portal for standardization in resolving of public works issues and improved assistance for Lombardy residents. The role of front-end employees/public service staff in co-creation. In co-creation sessions, front-end employees are essential for facilitating and guiding participant interactions. At PwC Experience Centers, there are two main types of employees working with external clients. The first group, are the creative specialists (digital engineers, industrial designers, UX technicians) that bring clients’ visions to fruition. The second group, are the facilitators of the co-creation sessions. The PwC staff in the facilitator roles are extensively trained in facilitator methodology and are well experienced at bringing together different perspectives in collaborative design thinking. Critically, the plurality of employees’ job profiles at the Centers allows for creativity in services offerings and guarantees that various types of clients will have the necessary personnel to execute the co-creation session objectives. To quote a Senior Manager at the Rome Experience Center referencing the value of staffing Centers with a variety of skillsets “the team (PwC) must be ready to support the different projects in every moment.” As aforementioned, the PwC staff act also in a ‘meta-consulting’ capacity – sharing information with and teaching internal PwC consultants. The normal managing consultancy team structures are not applicable to PwC Experience Center project teams. Instead, the front-end employees play dual roles as they are also actively participating in the co-creation process and the member composition is distinct from the usual partner, manager, senior associate, and junior associate team format. This is vital for co-creation to remain focused on the user and decentralized in structure. Additionally, the PwC Experience staff are tasked with procuring transformative interactions between stakeholders and ensuring that solutions from sessions are participant driven. This function is divergent from a typical PwC-client relationship, which can be less iterative and more unidirectional. The role of users/citizens in co-creation As noted in the section on how co-creation is outlived, co-creation prioritizes users/citizens at every stage and incorporates participatory design thinking. One of the main priorities of co-creation is iteration – allowing for user feedback and touch points throughout the development process. PwC considers customers/users/citizens as co-designers and their involvement is critical for avoiding product-centric outcomes and replication of past implementation mistakes. Part of PwC’s intermediary role is to relay the value of active user involvement to clientele, including public organizations and governments contracting the Centers’ services. This is executed through PwC’s creation of user and provider ‘personas,’ which helps cluster common characteristics and fosters mutual understanding among participants. Users/citizens need to feel a sense of commonality amongst themselves and development of personas also reveals universal concerns, frustrations, and challenges that were previously unacknowledged. There are several examples where PwC Experience Centers engaged multi-stakeholders and served as platforms where users/citizens could express their needs and wants of certain products/services. In the Lombardy case, for instance, in addition to the co-creation session PwC helped organize a call-for-feedback session, where Lombardy citizens were able to submit their opinions on the new public portal. Through this process, the Regione Lombardia could collect responses and better understand the fundamental issues of the application based on the user experiences. Another example, the Meet Sweden project pioneered by the PwC Stockholm Experience Center in partnership Swedish Industrial Design Foundation (SVID) and Swedish public agencies, highlights how the public sector is growing increasingly interested in the role of users/citizens in service model development. Asylum seekers in Sweden often struggle with long and arduous processes when trying to resettle and legally immigrate to Sweden. Information is lost between multiple visits to disjointed public organizations and refugees does not feel in control of their own asylum journey. To remedy some of these issues, PwC Stockholm brought together private and public actors as well as the migrants themselves at the Experience Center to participate in co-creation sessions and generate human-centric solutions. Assessing the needs of the migrants was essential when developing the layout and in-app design features in the Meet Sweden mobile application. As a result, the participants jointly created a new mobile application that streamlines the asylum process and saves time, money, and energy of all involved actors. This is just one project where livelihoods were improved based on co-creation design thinking and it exposes the potentialities of Experience Centers in enhancing public service delivery models. The role of other stakeholders (private actors, communities) in co-creation Given the Service Design for Growth delivery model’s emphasis on multi-stakeholder engagement, other private actors and the community at-large are valuable contributors, especially in co-creation sessions. Community stakeholder groups and private actors are active in participatory design thinking exercises in order to keep the target focus group, end users, at the core of solutions. Becoming representatives and managers of the public services/products instills important leadership characteristics in participants and ultimately facilitates self-governed, sustainable organizational processes.

Digital Transformation Process

PwC Experience Centers’ principal objective is to bring together customers and businesses in dynamic spaces to establish business models that incorporate user feedback at all design stages. In occupying this intermediatory role, Experience Centers help identify user needs and the root causes of customer dissatisfaction through co-creation processes so the resulting business model used by the client satisfies needs of end-users. This open-innovation environment attracts private companies and public organizations looking to modernize and transform the business-consumer service delivery relationship. Their human-centric nature makes these spaces distinct and helps concentrate varied perspectives and problem solving tactics in a central meeting location. Overall, PwC builds its Centers’ objectives around four key pillars:
  • Customer: placing the user at the center of the design process
  • Power of perspective: incorporating multiple perspectives in solutions
  • Always in Beta: maintaining iterative solutions that can be adjusted
  • Experiment with tech: enhancing existing tech and/or brainstorming new uses
  • Through iterative activities at the Centers, including group brainstorming in the Sandbox rooms, usability tests of company products and design thinking exercises, PwC works jointly with the public sector, its providers and the citizens to develop approaches that align with the above pillars. PwC intentionally outfits each Experience Center with adjustable, client-friendly workspaces and focuses on developing efficient and agile solutions. While Centers in every country belonging to the PwC network abide to a shared set of methodologies and approaches, each has its own focus and peculiarities. PwC structures each physical space differently to match regional and cultural characteristics. One example is the PwC Rome Experience Center. Inside the Center, there are flexible spaces with adjustable walls and moveable tables to accommodate activities organized for and with clients. It has a work café with objects of Italian design to create a familiar environment conducive to make people unwind and spur a positive ideation and reflection process. Additionally, the interactive technology and writeable walls incorporated in the central Sandbox meeting room offer clients unique spaces for meetings, workshops, and trainings with PwC UX design and technology professionals. The Testing Lab and Observatory Room include a unidirectional mirror so clients can carry out usability tests and observe real time client reactions to services/products. The Rome Experience Center also has AI technology, 3D printing, and contemporary digital programming to collaborate with clients in the development of prototypes. Typically, larger organizations have more rigid organizational hierarchies and learned cultural habits, which can make implementation of flexible methodologies difficult. The objective of the PwC Experience Centers are to function as testbeds and incubators for entrepreneurial design thinking and help PwC evaluate hybrid/agile managerial approaches to public sector challenges, in-house. By having the Centers operate in this way, PwC can overcome organizational challenges and share niche-consulting expertise gathered through Center activities to internal PwC consultants. This sort of ‘Agile Desk’ unit of PwC is transformative for internal work cultural – both enhancing workflow and teaching nuanced strategies for managing client relationships. There is a tri-fold benefit from PwC Experience Centers as clients, their customers, and PwC, learn and improve from the co-creation sessions and find solutions to broad, complex problems.

    Results, Outcomes & Impacts

    Living Labs play a critical role in displaying the mutual value of co-creation approaches for public and private actors. In the public sector, there is a hesitancy to welcome consumer engagement throughout the service design process. Governments and public organizations are fearful that actively seeking consumer input is too cost and time intensive and are unaware of the potential benefits for engaging customers in the earlier design stages. Therefore, it is essential to understand the PwC Experience Centers’ role in helping enable public-private mutual understanding and fostering innovative co-creation solutions. They add value by acting as a platform for idea exchange between all actors, inciting and analyzing customer feedback, and promoting multi-perspective discourse. The resulting improvement in services and increase in public value benefit the supply-side and user-side equally, and substantiates the importance of intermediaries in opening communication channels. It enables organizations and companies to explore how to improve their own services and/or processes with consumer engagement as the central focus and at the Centers they can test, fail, retest, and optimize proposed strategies before actual implementation. Social learning and/or contamination of techniques/approaches during interactions at PwC Experience Centers is another key way that public value is realized. Social learning refers to two simultaneous, complementary, and intertwined processes: innofusion (Fleck, 1988) and domestication of technology (Sørensen, 1996). Fleck defines innofusion as the innovation that takes place during the diffusion of new technology amongst participants. In this phase, users discover their needs and wants through a process of technological design, trial, and exploration. The other component, domestication of technology, addresses the pre-existing “heterogeneous network of machines, systems, routines and culture.” Essentially, it recognizes how cultural consumption habits influence user behavior and underlines the value of incorporating users’ creativity in product design processes. For PwC Experience Centers, a transfer of co-creation approaches and design thinking techniques to its participants is valuable for ensuring sustainability of solutions and enabling shared sponsorship to anticipate possible resistance to project implementation. Additionally, there is a cross contamination of techniques between participants as they originate from diverse backgrounds and bring to the workshops different views for how to solve problems. In this process, divergence in ideas and incorporation of distinct actors allows critical knowledge transfer that often precludes innovation and helps identify overlapping challenges. Outcomes generated from co-creation activities at the Centers have included the use of private sector business models by public organizations. By seeing the design elements of private sector models implemented by PwC, clients can interpret and apply similar structures in their own operations – thus initiating a transfer of proven strategies between private and public actors. The ability to measure performance varies from center to center, as there is not a standardized system of analysis at the macro level. At the above-mentioned PwC Stockholm Experience Center, they have begun testing ways to assess the effectiveness of their products/services in terms of end user impact. Labeled as a ‘creative audit,’ PwC Stockholm staff retroactively analyzed their work in the past year. The criteria used to measure impact were developed around questions such as “How many end users have we reached?” and “How many lives have improved as a result of innovative business and service models?” There is a distinction in how PwC aims to measure the performance of Experience Centers against the broader PwC mission, which has traditionally been more concerned with client value. The underlying driver for evaluation is improvement of end user experiences rather than profitability and other conventional business metrics. While still in its early stages, the results from the Swedish case to a certain extent validate the value of PwC Experience Centers as innovation incubators. In addition, external organizations and other Living Labs are also looking to collaborate with PwC to actively monitor the impact of co-creation in their respective sectors. Based in Norway, the Asker Welfare Lab, a citizen engagement lab that “adopts an investment mind-set and treats citizens as co-investors,” has contracted PwC to help develop key performance indicators for the lab’s projects. They are working with PwC to develop a measurement model that, together with Norwegian Association of Local and Regional Authorities, can monitor outcomes and trace results of how the lab is driving innovation. The PwC Experience Centers’ role in measurement practices is still yet to be determined, but validating the Centers’ activities and helping other labs track their progress are chief priorities.

    Transferability & Replicability

    It is expected that such digital transformation practice could be replicated in other parts of the Italian public administration if the need and the will is there, since it is the same socio technical conditions that apply. Whether such digital transformation can be replicated in public organizations located in other national contexts depends on the way public administration is organized in such contexts as well as the level of digitalization of both businesses and society.

    Success Factors

    PwC Experience Centers strive to alter existing unidirectional service/product deliveries. In regards to the service experience for users, more specifically there are two principal focuses:
  • Become more human centered in solutions for problems through qualitative based research approaches and human insight
  • Produce agile and iterative ways of working that draw multiple perspectives and provide timely/efficient testing of concepts for enhancing user experiences
  • Theoretically, in applying these principles PwC can foster multidirectional and collaborative relationships between developers and consumers. Improving co-creation interactions has two potential effects for the customer: (1) It reduces transaction costs, risk, and uncertainty, and (2) it reduces the costs of the interaction for the consumer, which leads to greater satisfaction with and trust in the company (Rajah et al, 2008). These improvements for the customer are interlinked with enhanced productivity for the supplier and for the contracted firm (PwC in this case). In working with the end users throughout the co-creation process, subsequent organizational models used by clients reflect specificities of the customers and provide material for PwC Experience Staff to utilize in their role as meta-consultants to the firm. The resulting service experience/relationship is circular, valorizing iteration and human input in design. Clients and customers can walk away from experiences at the PwC Experience Centers with new levels of understanding and transparency, which then translates to sustained changes in business models and provider-customer relationships. Uniquely, the Experience Centers allow PwC to diversify its approaches away from traditional Stage-Gate methods toward more Agile On-Demand approaches and this has also impacted the inside work culture at PwC. Stage-Gate is a methodology where the project is divided into separate phases and the manager leads the continuation of the process. Developed to avoid reworking or redirecting processes, the Stage-Gate model remains limited in its ability to incorporate external feedback and in its dynamism. Amidst the digital revolution, Agile approaches emerged and gained traction as they were inherently more responsive and emphasized the role of people over processes. At PwC, the adoption of Agile methodologies by its Experience Centers has expanded and permeated across other business units and has attracted new and varied clientele. Further, through the Experience Center unit, PwC experiments with additional forms of flexible approaches and this has contributed to its successes in rapidly developing product/services that alleviate misalignments between the client and their customers.  In the public sector, transforming the service experience to be more human-centric is growing in popularity and in several cases PwC’s involvement has helped spur new private-public partnerships. Another use case from the PwC Stockholm Experience Center is the Storsthlm project. In response to Stockholm’s recent growth, the Greater Stockholm municipalities needed to reorganize management processes in the areas of politics and public administration. Together with PwC, the municipalities and the County Council collaborated on the Health and Support initiative as part of the new Regional Development Plan that aims to enhance citizens’ mobility and access to public resources. One aspect of the plan focused on improving public assistance programing for the aging population. Within the PwC co-creation sessions, outputs were constructed around a core objective: How can we make sure to deliver on helping citizens through the aging process? In working with the public municipalities, engaging with elderly citizens, and integrating co-creation methodologies, PwC helped keep the solution human centered and rooted in qualitative research. The municipalities reinvested in their citizens and relied on PwC business approaches to solve reoccurring issues in administering of public services. This resulted in improved interconnectivity between municipalities and a collaborative program design that moved away from typical silos and disjointed public assistance organizations in the public sector.

    Stakeholders & Beneficiaries

    NEMO exists to take care of patients with neuromuscular diseases and their families. They are frequently grouped in family associations. The team of doctors, specialists, nurses and the management are all devoted to putting the patients at the centre of the treatment / care. The city of Messina is talso an important community for Nemo in terms of local support, because the city is small, so the Centre is more representative within that context and all the community is involved in the project. When patients die, the family raise donations for the Centre, and all of the persons involved participating in all the stages, even in the death moment. Professionals also mention ASL – the local public healthcare institution, but maybe even more important are the suppliers/home care providers, that understand the functioning and the bureaucracy to which they are subject to and are flexible in efficiently providing Nemo with necessary supplies.

    Co-creation process

    Co-creation is taking place in all three phases: planning, structuring and service delivery. Not yet in the part when patients go home (domicile phase), as the Centre is not completely well structured for that yet. According to patients, value is created in both the design and the delivery of services, as Nemo works, in co-creation, co-production with them, on innovation, listening to their needs and treating them with dignity. The importance of the families’ integral participation in the process is highlighted in the professionals’ testimonial as well. All stakeholders also agree on the evaluation of services, as it allows the professionals to redesign and adapt their service, which do not exist separately, but it is a result of all phases in which the patient is present.

    Results, Outcomes & Impacts

    The patients and families are all very satisfied with the non-standardised, or individualised, care model applied in Nemo. They rate each professional they meet during their treatment on a scale from 1 to 7 as follows: nurse coach: 6,71; physiotherapist: 6,65; nurse: 6,76; speech therapist: 6,69; doctor: 6,75. According to page 21 of the CSS report, their perception of the treatment received from their arrival through their stay in Nemo’s facilities is as follows: possibility of accessing Nemo 24/7: 6,69; respect to their privacy: 6,67; their perception of being treated as a person, and not just as a patient: 6,60; respect and approach regarding their religious beliefs: 6,59; dedicated spaces to leisure time (recreation, tv, games): 6,56.

    Challenges & Bottlenecks

    In spite of the unarguable evidence collected in the different fieldwork approaches regarding value creation, the question of value destruction was also brought up by some of the involved parts. Nurse coach brought up the risk from the part of healthcare professionals of being too involved in their jobs and ultimately “loosing” their sense of personal life. Also, the “excess” of care can highlight a consequence of value destruction for the patients as they could expect too much care and forget that they have a brute, degenerative pathology that needs an active role from them too to be fought. Political relations must be carefully managed too, otherwise a wrong move can lead to value destruction, like in the nonprofit world, where egoism of its actors can sometimes lead to conflicts and disruption, or in the social media world, with the propagation of various news, which can generate conflicts and disruption in the value creation process. Finally, the risk of creating excessively high expectations and not delivering what patients expect, i.e. the cure, because it has not yet been found for neuromuscular diseases, also represents a big challenge.

    Transferability & Replicability

    The model of the nurse coach is already inspired from something that is well-known in the U.S. Model. Also, the methodologies is applied in four different clinical facilities throughout Italy. So, the clinical medical concept it not related to any very specific, local context and can be replicated or transferred.

    Success Factors

    Creating a symbiosis among all the stakeholders is what makes the individualised care system work: patients must be aware and feel confident towards the multidisciplinary team; healthcare professionals must carry certain types of value (respect, dignity, etc.) not only in their professional life but also in their personal one to be able to use them with the patients; family associations play a crucial supporting role (financially, emotionally, in research); the supplier/home care providers, that understand the functioning and the bureaucracy to which they are subject to and are flexible in efficiently providing Nemo with necessary supplies, are facilitators; the local health public institutions need to be involved as well; and the citizens and communities are key too. All stakeholders work hand in hand towards the same goal, i.e. allowing people with neuromuscular diseases to not only survive but actually live quality lives.

    Lessons learned

    Evaluations are critical to constantly improve the services and keep as close as possible to the patients’ needs. Through constant monitoring of how much they offer to every patient, they can improve the answers to treatment needs. Based on this principle, they have developed a system for evaluating the satisfaction of patients accessing the services, based on their perception of the care/operating model. In concrete, Nemo has developed a customer satisfaction survey which is the result of a multidisciplinary work, through which the professionals of Nemo have expressed their point of view on the issues to be evaluated. For the first time, topics such as the respect for the individual and his/her choices, the perception of being ‘at the center of care’, welcoming to the patient’s family nucleus, were studied. This system also allows for the healthcare professional to redesign their role based on the indicators that are measured not only by the patients, but also by the public healthcare system.

    Stakeholders & Beneficiaries

    MAIA aims to ensure the decision-making process (interaction, collaboration) between stakeholders at two levels: at a strategic level – in order to develop a collaborative and decision-making space between decisionmakers and funders of gerontological policies (ARS, departmental councils, and others); at a tactic level – in order to create a collaborative and decision-making space between the operators responsible for the healthcare and support services that help seniors to stay at home. For seniors in complex situations, an intensive and long-term follow-up (including during hospitalisation periods) is implemented by a case manager (a new professional skill). This professional is the direct contact with the senior, with the general practitioner, with the professionals working at the senior’s home, and becomes the referent of complex situations.

    Co-creation process

    At the institutional level, there is a top-down approach to co-creation, designed to better fit the realities of the territories: the Regional Health Agency selects, via a call for application, an infra-departmental institution (non-profit organisation) which can mobilise local actors. This non-profit will be in charge of implementing the MAIA pilot on its territory, by connecting the professionals in healthcare to fit the territorial reality. At the user level, the co-creation materialises through the dialogue between the senior (the user) and the case manager, who becomes the spokesperson for the user and translates the user’s needs and wishes to the healthcare professionals (sometimes against the advices of the health professionals).

    Results, Outcomes & Impacts

    In its interactions with the users and professionals, the care manager helps to improve the organisation of the care system by identifying any dysfunctions observed on the territory.

    Challenges & Bottlenecks

    According to Policy maker, MAIA activity reports are done by the MAIAs but require a thorough understanding. Starting to introduce indicators for measuring value creation raises problems relating to the instrumentalisation of such indicators. Ideally, a territorial roadmap used by all the operational actors would be interesting to develop, but given the fact that data would be analysed on a very small territorial scale and then structured at a regional and national level, it requires money and tools. This is not done today. Monitoring indicators have been developed and used during the implementation stage of the MAIA method (e.g. number of contacts a senior must have established to access to the right resource). Currently at the local level, the impact in terms of organisation is measured (participation rate of partners at the tactical table, or for the case management, the territory distribution of seniors being managed). It has been noted that the participants to the tactical tables are always the same volunteers, actors who encounter difficulties in their daily practice do not often wish to participate (as this could be viewed as failure) and general practitioners are rarely part of the table. According to the pilot at the local level, a tool has been evaluated, but there is no local evaluation of the value creation of the MAIA for the territory. It would be interesting to know for example the impact of MAIA on the reduction of hospitalisation in emergencies, the reduction of user orientation towards wrong services. The partners should be involved to create these indicators. For the case management, the value creation is evaluate via the decreasing needs of the senior that the case manager has to fulfill. The creation of value can be measured via satisfaction surveys but this is not a global value creation, that is, the medico-social system as a whole. Care Pathways Operational Committees are currently working on impact indicators (non-use of emergency, scheduled hospitalisation). The current problem is that the databases are currently partitioned between the medico-social, social and sanitary field, so there are difficulties to measure the impacts on a pathway of a user. Finally, MAIA is on a voluntary basis, so there is no incentive (legal, financial), for professionals who are solicitated to take part in brainstorming sessions and one can find always the same people involved.

    Transferability & Replicability

    This initiative is applicable to the various sub-territories of the French regions, because of its very locally-oriented – and even user-oriented approach. The concept is therefore replicable to other territories. Also, the MAIA project was already copied from a similar initiative in Quebec, Canada.

    Success Factors

    An integrated, one-stop service provides, at any place of the territory, a harmonised answer adapted to the needs of the users, by directing them towards the adequate resource. It integrates all the reception and orientation counters of the territory. The MAIA method includes the development of common information-sharing tools and action-steering tools (a shared multi-dimensional analysis form, a standardised multidimensional needs assessment tool, and individualised service plan). If the MAIA method is originally top-down, once the project holder chosen by the network, the deployment is left to the initiative of the Maia pilot. Thus, this method is deployed on territories in very different even innovative ways, depending on the diversity of actors and networks already existing on the territory. Thus, the approach is considered as “help-it happen” by the policymakers. Various forms of MAIA multi-stakeholder networks have emerged at a territorial level.

    Lessons learned

    All respondents have stressed that it is difficult to determine the moment of value creation. National and regional public manager, partners, pilots agree on the fact that the creation of value of the MAIA method is mostly upstream, as a back-office function, during the constitution of the network, when the pilot and the partners discuss together to facilitate the articulation between services (creation of a professional dynamic). The users here are the partners. Thus, the value creation takes place before the services are delivered. However, the respondents point at that the value creation is also continuous, throughout the accompaniment of seniors all over the care process (according to the national and regional public manager and partners). When a single patient joins the healthcare system, this is value creation. According to the case manager, the value is created once the professional chain around the senior is stable and complete. Thus, mostly once the service is delivered, even if the senior monitoring continues to be provided.

    Stakeholders & Beneficiaries

    Regarding the actors most relevant in the process of value creation, clearly the purpose of policymakers is to create value and co-creation is a means for them to do their job better. However, the value created by having more insights helps not only the strategic level, but also at the operational one. Therefore, the elderly people are the centre piece in value creation: they are involved in the service design phase, as in the evaluation phase as testers, who give directions to the companies and the city administration to adapt product or services to their special needs.

    Co-creation process

    Regarding the concept of co-creation, interviewees stressed the fact that users and companies involved provide specific insights can help for the design of the project and of the public services. For instance, in ZorgLab people involved in the co-creation activity provided their own insight on which are the tools most useful for everyday life and how it is become more difficult for them to use such tools. Also, they provided their insight on how the house should be organised, also taking into account the necessity to keep a rich social life. An interesting aspect of co-creation is also mediation, as different individuals do not share the same idea of what is a liveable and sustainable neighbourhood. For what concerns the kind of value created in the service, as afore mentioned the initiative from one side wants to enable elderly people to stay longer at home in an independent way. From the other side, people involved in the co-creation activity have an experiential value, as they can give their contribution and still be active in the society. In the respect, for them it is very important to have a true recognition of their effort on the side of the policy makers. Interviewees reported some cases in which policymakers consult but do not follow the insights in the end. Apart from participation aspects, co-creation is also seen as a mean to increase democracy and social cohesion, like the example provided Bologna City of Commons project, where citizens can take initiatives to organise their lives together. On the other hand, such initiative has also a clear economic value, as it brings more companies in the healthcare sector so it can be an economic differentiator for the city. In fact, in the ZorgLab facilities, companies can test their innovation, make better products and have a real economic impact. So, Aalst is really becoming a city based on the healthcare sector and ZorgLab of course has been an advantage in comparison to other cities. Value is created in every stage of the initiative, but especially in the beginning where the insights are extracted from the participants to the co-creation activities. It is crucial to be able to extract such insights combining people working alone and in group: there rarely is a Eureka moment when you do co-creation. So clearly it is the interaction that creates the most value, even though the same value it is delivered at the end of the project (e.g. improved living condition for the elderly). Regarding the actors most relevant in the process of value creation, clearly the purpose of policymakers is to create value and co-creation is a means for them to do their job better. However, the value created by having more insights helps not only the strategic level, but also at the operational one. Therefore, the elderly people are the centre piece in value creation: they are involved in the service design phase, as in the evaluation phase as testers, who give directions to the companies and the city administration to adapt product or services to their special needs. In this regard, the service experience/relationship is paramount in the creation of tailor-made products and services for the elderly, especially for what concerns the interaction between front-line staff and the service user. Front-line staff are linking all stakeholders together, so that they can meet and create value. A continuative relationship reinforces also the co-creation activity as individuals get really motivated and experienced so that the feedback you get from grows in quality. It is very important to work closely and to have proofs the approach is working since from the beginning. Also, it is crucial not to have an academic approach, but to work closely with the participants learning to really listen carefully and understand exactly what they need, in order to gain their respect and to get relevant information from them. Considering the contribution of citizens or communities to the process of value creation, there is a clear distinction between participation (sharing ideas and taking part to decision) and co-creation (really being part of the process of creation). In that respect, only the most motivated citizens really provide great effort. In that regard, it has also to be considered that individuals taking part to co-creation activities are also the most cultivated and well-off, as it is very complicated to motivate marginalized individuals.

    Results, Outcomes & Impacts

    As already mentioned, the aim the case study is to investigate the concept and process of value creation and co-creation in the initiative. In this respect, value was defined by interviewees as any benefit for users or citizens stemming from the use of the public service as well as from the participation of the co-creation activity. In this specific context, value is conceived as the benefits of potential and actual users of the elderly home, who will be able thanks to the service to live longer and safer independently and to continue to be part of the society. On the other hand, the volunteers taking part to the testing keep being socially active and to provide their contribution to society with this project. So, they feel they are still having an aim in their life.

    Challenges & Bottlenecks

    A first obstacle is regulation hampering innovation, not only at local level, but also at Flemish, Belgian and European levels, especially for what concerns data sharing and assisted living. Furthermore, often private companies have a wrong estimation of co-creation, which is seen as a way to quickly get feedback on a developed product, rather than a way to co-create a product from the beginning. Clearly the latter process is more time and money consuming. Also, it is difficult to convince the elderly to test the house living there from 1 to 3 weeks: in that regard, direct contact with them helped. A final obstacle and drawback is the lack of structures to evaluate the impact of the initiative and to measure value. In fact, there are some evaluations of the Flanders living labs overall, but not for any of the local project. But in any case, how do you measure value? Measuring contacts and interactions face to face and on social media is not a really metric or indicator of value. On the other hand, value is not limited to the economic gains from an initiative. Overall, value can be measured only by mean of subjective reported impressions in questionnaires, so that generalization is difficult. Regarding the specific case, one possible bottleneck is also financial because if the product/service produced is too expensive or if people with low budget cannot really address the service the goal of the process is lost.

    Lessons learned

    The most important mean to involve citizens in co-creating value is to recognize their effort and to show them that their views and insights have been taken into account. Another crucial aspect is a good definition of the objectives of the co-creation activity. In this respect, it would be helpful to teach individuals to work with design-thinking to some extent. Organisations and companies sometimes come with big expectations about co-creation, as they expect to come up with fully new products. However, only the small things can be innovated at a time and often small things make the difference in the end. Also, lots of organisations are coming too late in the co-creation process: they just want to quickly test their product, instead of testing their idea first and progressing along the way. Also, many of their ideas stem from technology itself, which is sees as a solution itself rather than as a mean to bring about change. Another important aspect is to pay attention to the quality of participants: projects need to involve a lot of professionals and future users of the service, because their insights are the most important part in the process of co-creation. For example, dignity is key element for future users, together with the fear of independence loss in the elderly home. An interesting idea concerning the selection of participants is to combine users and experts, and in any case to provide a benefit for the user /expert to participate in terms of moral recognition of their contribution. A final important element consists in the development of the right context for such kind of projects, based on a strict collaboration among caring facilities, hospitals, services and products providers, policy makers and civil servants. A follow up project could be to rethink the public elderly homes, as well as to influence the current culture of staying too long in our home, by convincing individuals to move to another more sustainable home.