DOCTORAL THESIS IN TECHNOLOGY AND HEALTH - KTH ROYAL INSTITUTE OF TECHNOLOGY - DIVA
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kth royal institute
of technology
Doctoral Thesis in Technology and Health
Serious Game Approach for
Improving Healthcare Logistics
CHEN ZHANG
Stockholm, Sweden 2020
Serious Game Approach for Improving Healthcare Logistics CHEN ZHANG Academic Dissertation which, with due permission of the KTH Royal Institute of Technology, is submitted for public defence for the Degree of Doctor of Philosophy on 14th of October, at 9:30 a.m, in Hälsovägen 11C, Stockholm Doctoral Thesis in Technology and Health KTH Royal Institute of Technology Stockholm, Sweden 2020
© Chen Zhang ISBN 978-91-7873-645-4 TRITA-CBH-FOU-2020:51 Printed by: Universitetsservice US-AB, Sweden 2020
Abstract Although serious games are central to corporate learning of needed skills for industrial operations sectors, their use for managing healthcare logistics has rarely been discussed from the perspective of game mechanics in terms of motivation, engagement and the achievement of the desired objectives. This thesis discusses serious games as a method for improving healthcare logistics with a case study in paediatric emergency medicine. This case is also exemplary for many other situations in the hospital sector. To understand the methodological state-of-the-art, in the first study, a systematic literature review of the simulation and gaming methods used to address logistical issues in healthcare was first of all performed based on eliciting two-hundred-and-seventy-three identified journal articles. The review found that the simulation studies focused on the modelling of work system mechanisms, whereas the introduction of game elements specifically designed for promoting desired behaviours, although pertinent, remained unexplored. Consider the type of problems that are addressed using simulation models, these models may be ideal candidates for addressing a wide variety of logistical issues. Intrigued by these findings, the second study explored a serious game design based on a simulation model representing patient flow characteristics and systemic resource configurations. The results indicate that the participatory allocation of resources would improve pure simulation-based predictions; nevertheless, the players felt challenged for a total management of the simulated emergency department. The simulation with a participatory aspect provides a challenging environment flexible enough to account for the demand-and- provision balance, preferences from actors, and the use of relevant game mechanics to reflect logistical aspects. This led to the third study incorporating the roles of the managers responsible for patient flow stratification in a parallel functioning healthcare production system and the specially designed scoring-based feature on top of healthcare production logistics to facilitate desirable behaviours in favour of overcoming access blocks and to monitor learning
progress in corporation training situations. These features were tested in game-based learning activities under different modalities. Scores for the Game Experience Questionnaire and the data of in-game learning behaviours were collected to allow quantitative research to evaluate the experience, acceptance and effect of learning. The serious game in this thesis contrasts with that of previous applications in health which tend to be less challenging and of low difficulty levels. Scores and transitions of learning behaviours stems from a game design aiming to achieve the expected outcomes in learning the logistical management principles of healthcare and the delivery of the production decisions in a meaningful manner. In order to understand the effect of environmental stimuli on decision- making processes, in the fourth study, behavioural aspects were investigated in a more detailed level. Choice modelling of the revealed data from most of experiments was conducted to further estimate the efficacy of game elements as factors potentially influencing healthcare production decisions. The results showed that the effectiveness of the proposed scoring system is approximately identical to that of the contingent game elements, whereas the diminution of resource utilization is detrimental for choosing the patient transfer alternative. Certain suggestions on game design were also made. This thesis showed that a serious game, if rightly designed, could be a valuable tool in the case of practising decision making processes in health systems and understanding the impact of environmental parameters in a simulated environment with real operational data. The thesis might also serve as a reliable source of reference for game designers who wish to model and simulate complex social-technical systems that can be dictated by operational circumstances. Keywords Serious game, Simulation, Decision-making, Production choices, Emergency medicine
Sammanfattning Även om seriösa spel är centrala för företagslärande av relevanta färdigheter i industriella verksamhetssektorer, har deras användning för sjukvårdslogistik sällan diskuterats ur spelmekanikens perspektiv vad gäller motivation, engagemang och uppnående av de önskade målen. I denna avhandling diskuteras seriösa spel som en metod för att förbättra vårdlogistiken, illustrerat med en fallstudie inom pediatrisk akutmedicin. Detta fall är också representativt för många andra situationer inom sjukvårdssektorn. Som första studie utfördes en systematisk litteraturundresökning för att kartlägga det allra senaste inom metodik för simulering och spel för logistiska frågeställningar inom hälso- och sjukvården, detta baserat på 273 identifierade vetenskapliga tidskriftsartiklar. Granskningen visade att simuleringsstudierna främst fokuserade på modellering av arbetssystemmekanismer, medan införandet av spelelement som utformats särskilt för att främja önskade beteenden, även om de var relevanta, förblev outforskade. Med tanke på de problem som hjälpts att besvaras genom simuleringsmodeller, kan dessa modeller vara lämpliga kandidater för att utforska en rad frågeställningar inom logistik. Som en vidareutveckling utforskade den andra studien en seriös speldesign baserad på en simuleringsmodell som representerade patientflöde, dess egenskaper och systemiska resurskonfigurationer. Resultaten tydde på att deltagarstyrd resursfördelning kan förbättra simuleringsbaserade prognosresultat. Spelarna kände att en total hantering av den simulerade akutmottagningen var utmanande. Simuleringen med deltagaraspekter tillhandahöll en utmanande miljö som var tillräckligt flexibel för att ta hänsyn till efterfrågan-och- provision balans, aktörers preferenser, samt användande av relevant spelmekanik för att reflektera logistiska aspekter. Detta ledde till att den tredje studien innehöll roller för de chefer som ansvarar för patientflödesstratifiering i ett parallellt sjukvårds- produktionssystem och den specialdesignade poängbaserade funktionen ovanpå logistiken för hälso- och sjukvårdsproduktion. Detta för att främja önskvärda beteenden och övervinna åtkomstblockering, samt
övervaka inlärningsframsteg i företagets utbildningssituationer. Dessa funktioner testades i spelbaserade inlärningsaktiviteter under olika modaliteter. Poäng från Game Experience Questionnaire och data från inlärningsbeteenden i spelet samlades in för att kvantitativt utvärdera inlärningens erfarenhet, acceptans och effekt. Den seriösa spelet i denna avhandling kontrasterar mot tidigare tillämpningar inom hälsovetenskap som tenderar att vara mindre utmanande med låg svårighetsgrad. Poäng och övergångar i lärandebeteenden härrör från en speldesign där det gäller att uppnå de förväntade resultaten vad gäller att lära sig hälso- och sjukvårdens logistiska förvaltningsprinciper och leveransen av produktionsbeslut på ett meningsfullt sätt. I den fjärde studien undersöktes beteendeaspekter på en mer detaljerad nivå för att försöka förstå effekten av miljöstimuli på beslutsprocesser. Modellering av beslutsprocesser från experimentell data genomfördes för att ytterligare skatta effekten av spelelement som faktorer som potentiellt påverkar beslut I sjukvårdsproduktion. Resultaten visade att effektiviteten i det föreslagna poängsystemet är nära identisk med den för kontingenta spelelement, medan en minskning i resursutnyttjande påverkar alternativ för patientöverföring negativt. Vissa förslag på speldesign kunde också ges. Denna avhandling visade att ett seriöst spel, om rätt utformat, kan vara ett värdefullt verktyg för träning angående beslutsprocesser i hälso- och sjukvårdssystem och för att förstå inverkan av miljöparametrar i en simulerad miljö baserad på verkliga driftsdata. Avhandlingen kan även tjäna som en pålitlig referenskälla för speldesigners som vill modellera och simulera komplexa social-tekniska system som styrs av operativa omständigheter. Sökord Allvarliga spel, Simulering, Beslutsfattande, Produktionsval, Akutmedicin
List of Papers Paper I C. Zhang, T. Grandits, K. P. Härenstam, J. B. Hauge, and S. Meijer, A systematic literature review of simulation models for non-technical skill training in healthcare logistics, Advances in Simulation, vol. 3, no. 1, Jul. 2018. Paper II C. Zhang, K. P. Härenstam, S. Meijer, and A. S. Darwich, Serious Gaming of Logistics Management in Paediatric Emergency Medicine, International Journal of Serious Games, vol. 7, no. 1, Mar. 2020. Paper III C. Zhang, J. Baalsrud Hauge, K. P. Härenstam, and S. Meijer, Game Experience and Learning Effect of a Scoring-based Mechanic for Logistical Aspects of Paediatric Emergency Medicine, JMIR Serious Games, revision, Aug. 2020. Paper IV C. Zhang and S. Meijer, Estimating the Effect of Game Elements on Healthcare Production Decisions: Choice Modelling based on Serious Gaming, Submitted to Entertainment Computing, Sep. 2020.
My contributions of the listed papers Paper I: The research idea was facilitated by Zhang, Grandits and Meijer. Zhang suggested the adherence to the PRISMA protocol and worked together with Grandits to inquire research articles. Zhang and Grandits conducted a paper-to-paper examination, categorized papers, came up with major conclusions and wrote the systematic literature review. Pukk Härenstam and Baalsrud Hauge and Meijer supported the in editing and writing. Zhang and the supervisors were addressing comments from reviewers and stayed contacted with the editorial team until the article was published. Paper II: The research idea was facilitated by Zhang and Meijer. Zhang performed the field visits, downloaded the flow data from the enterprise resource planning system of the modelled emergency department, and constructed the simulation. Zhang wrote the paper with subject domain guidance from Kiku Härenstam. The supervisors supported in highlighting the contributions of the paper. Darwich supported in writing. Zhang was addressing comments from reviewers and stay contacted with the editorial team of the journal until the article was published. Paper III: The research idea was discussed and finalized between Zhang, Pukk Härenstam and Meijer. Zhang realized the serious game in modalities with design and development feedback from the supervisors. Zhang was the facilitator of game sessions and collected play data from the participants. Zhang processed, analysed, and interpreted the data with feedbacks from Baalsrud Hauge and Meijer. Pukk Härenstam helped editing some chapters of the contribution. Zhang and Meijer were addressing comments from reviewers and stayed contacted with the editorial team of the journal. Paper IV: The research idea was facilitated by Zhang and Meijer. Zhang prepared the dataset based on the results of the third paper and on the proceedings from the sessions. Zhang constructed, estimated, and interpreted the behavioural model. Zhang wrote the paper with feedback provided by Meijer on clarifications, justifications, and positioning of research efforts in the literature of activity-based models.
Related publication, not included in the thesis Paper V C. Zhang and S. Meijer, “A Simulation Game of Patient Transportation,” in Neo-Simulation and Gaming Toward Active Learning, R. Hamada, S. Soranastaporn, H. Kanegae, P. Dumrongrojwatthana, S. Chaisanit, P. Rizzi, and V. Dumblekar, Eds. Singapore: Springer, 2019, pp. 53–66. Paper VI C. Zhang, J. Baalsrud Hauge, K. P. Härenstam, and S. Meijer, “A Serious Logistical Game of Paediatric Emergency Medicine: Proposed Scoring Mechanism and Pilot Test,” in Games and Learning Alliance, vol. 11899, A. Liapis, G. N. Yannakakis, M. Gentile, and M. Ninaus, Eds. Cham: Springer International Publishing, 2019, pp. 468–478. The author’s contribution in those publications was proposing research ideas, research design, data collection and analysis and writing the papers. Paper V was a theoretical contribution. Paper VI was extended to Paper III to incorporate an improved structure of the scoring system and to employ multiple quantitative methods for the exploration of the game experience and learning telemetry.
Acknowledgement Many organizations, both governmental and institutional, in Sweden and many individuals from the industry kindly provided, by different opportunities, a large proportion of the inspiration and information necessary for writing this thesis and attached articles. To all of these I would like to deliver my sincere gratitude for the very much needed helps and supports. However, it would miss the boat not to delivery my appreciation for the assistance provided by Kiku Pukk Härenstam, a researcher of quality and safety engineering and an experienced physician in paediatric emergency care, Jannicke Baalsrud Hauge and Sebastiaan Meijer, experts in gaming simulations and production logistics, and all the fellows affiliated to the School of Technology and Health. I wake up every morning to believe that thesis is all about myself, yet various gaming and simulation organizations have been the drivers of fruitful discussions and inspirational references, particularly; the International Simulation and Gaming Association, and the Gaming and Learning Alliance; both of these are Europe-based organizations. I am also thankful for the significant knowledge and lessons learned about the field from participating conferences affiliated to these boards. Acknowledgement is made to the KTH-CSC funding (agreement number: 201600160048); Nordforsk for the International Doctoral PhD course of Analysis and Modelling for Sustainable Manufacturing and Logistics offered by Carisma RCT Ltd. in collaboration with the Norwegian University of Science and Technology and Emerald Group Publishing; and Jubilee foundations for my travelling to conferences.
Contents
1. Introduction ......................................................................................................1
1.1 Strides taken by gaming applications ....................................................2
1.2 Serious games in operations management teaching and learning ....4
1.2.1 Medicine and health ..........................................................................4
1.2.2 Logistics and transport management..............................................5
1.2.3 Energy management ..........................................................................6
1.2.4 Urban planning and management ...................................................6
1.2.4 Roadmap for serious gaming: summary .........................................7
1.3 Research questions ....................................................................................8
1.4 Case study description ..............................................................................9
1.5 Research objectives ................................................................................11
1.6 Research contributions ...........................................................................13
1.7 Thesis outline ...........................................................................................16
2. Methodological review ..................................................................................18
2.1 Gaming and simulation ...........................................................................18
2.2 Behavioural choice modelling of healthcare production decisions 22
2.3 Analytical approaches to gaming experience and learning
telemetry .........................................................................................................23
2.4 Logistics management principle in healthcare productions ............24
2.5 Game design approaches........................................................................24
3. Research summaries ......................................................................................25
3.1 State-of-art of simulation and gaming for healthcare logistics ......25
3.2 A simulation model of a healthcare production system ...................283.3 Game mechanics selection for production types of games..............30
3.4 Game design and development .............................................................33
3.5 Game experience and learning telemetry ..........................................38
3.6 Estimating the impact of game elements ...........................................40
3.7 Simulation predictions enriched by gameplay outcomes .................41
4. Meta reflection and methodological discussion .......................................43
4.1 Implications on game design approach ................................................43
4.2 Implications on game mechanics ..........................................................44
4.2.1 Review on the planning mechanic ................................................45
4.2.2 Review on the status mechanic .....................................................45
4.2.3 Review on the selection and production choices .......................46
4.2.4 Representation of complexity ........................................................46
4.3 Strengths and weaknesses of contributions ........................................47
5. Synthesis and future perspectives ..............................................................50
References ...........................................................................................................54
Articles .................................................................................................................66Definitions
Serious game: games that do not have entertainment, enjoyment or fun
as their primary purpose (Michael & Chen, 2005)
Educational game: games specifically designed to teach a certain subject,
expand concepts, reinforce development, understand an historical event
or culture, or learn a skill (Spaulding, 2012)
Simulation game1: games that are tempering realistic situations in
interactive settings for purposes of training and analysis
Business simulation: simulations, games and experimental techniques as
teaching methods in the disciplines of business, management, and
related fields (The Association for Business Simulation and Experiential
Learning, retrieved August 2020)
Social simulation: a research method and field that applies
computational methods to study issues in the social sciences (Takahashi,
Sallach & Rouchier 2007)
Edutainment: the process of entertaining people at the same time as you
are teaching them something (The Cambridge Dictionary)
Abbreviations
ED: Emergency Department
GEQ: Game Experience Questionnaire
PT: Production throughput
AE: Activity executions
RM: Resource management
PR: Production resilience
MR: Managing resources
1
Working definition.EP: Editing profiles IC: Inviting cooperation FT: Finishing tasks
INTRODUCTION | 1 1. Introduction Pressure on healthcare systems persists at the global level. Over 2019- 2023, health spending is expected to grow by 5%, up from 2.7 % over 2014-18 [1]. For the major markets, the BRICS will encounter a 117% increase in health spending in the coming decade, and increases are projected for all developed countries and regions [2]. The increasing demand for healthcare is being driven by a broad set of factors such as socio-demographic changes, growing expectations of quality and safety care, a shortage of a qualified workforce, and the evolution of business models. Consequently, governments and agencies must respond with efficiently delivered care. A timely and effective logistical flow is paramount for dealing with healthcare demands on that regard. The need for corporate training is higher than ever in fighting against an increasingly challenging operative environment and overcoming access blocks across hospitals. To achieve systems engineering aims, researchers and scholars have started to adopt gaming methods in recent years [3] [4]. As understood by the present academic sphere and industrial sectors, serious games and simulations with participatory inquiries appear to be a type of gaming purposed for contextual applications with desired objectives and balancing of an entertainment computing system and representation of reality. The first serious game recognized in the populace, namely the HUTSPIEL suit published by the Operation Research Office from John Hopkins University to simulate the devastation that would occur in a global nuclear war [5], was published even long before the video games worked as the mainstream of play and fun in the digitalization era [6]. Finally, The emergence of serious games as a field has been facilitated by Abt’s quote in his book [7]: “Games may be played seriously or casually. We are concerned with ‘Serious Games’ in the sense that these games have explicit and carefully thought-out educational purpose and are not intended to be played primarily for amusement. This does not mean that serious games are not, or should not be, entertaining.”
2 | INTRODUCTION Although the development of the field benefits from the rapid accomplishment of modelling and simulation technologies, serious game design and application are inspired by games in historical settings. Board games were mostly relied upon in the majority of human history before the invention of computers and are still being accepted as an important modality [8] [9], as they provide advantages in the representation of the complexities of social interactions. It is therefore critical to understand from the ancestors of today’s games which characteristics, indications from the outcomes of play and other aspects making gaming and simulations successful in formative situations. 1.1 Strides taken by gaming applications Reading across research records, the oldest fully functioning game associated with clear outcomes of play was the sandtable chess match crafted by Gongshuban in 450 BC. As a civil engineer and architect, Gongshuban in his dialogue with Mo Zi used models of military tuples for a regional administration planning effort in the sinosphere ChunQiu era [10]. In order to establish a reasonable consensus, Mo Zi allotted a belly belt and the food plates to represent the city and deployable machineries, whereby Gongshuban came about tactics and skilled crafts on the offensive side of the simulation. After a back-and-force process, Gongshuban was not able to take advantages across the board after Mo Zi discovered the optimal combination of the stone catapult, crossbows and logistical bars to defend against scaling ladders. This exchange of ideas based on facets of a real-world system forecasted various scenarios, remarkably steering the whole planning process to a successful project. In approximately 400 BC, despite different opinions at the intersection of gaming and learning, Plato and Aristotle wrote about the meanings of play and explicitly outlined their recreational and education purposes. As the timeline in Fig.1 illustrated, the advances in gaming theory continued until Huizinga published Homo Ludens [11]. In this book, the five characteristics of games were defined as (1) playing a game is freedom, (2) playing a game is not real life, (3) the locality and duration of games are distinct from ordinary life, (4) playing a game demands absolute and supreme order, and (5) playing a game is not connected with material interest or profit.
4 | INTRODUCTION to training skills or the communication of specified messages to participants. 1.2 Serious games in operations management teaching and learning For either conveying important messages to recipients or purposeful training of soft skills, serious games fit well in management teaching and learning situations; they allow user-centred inquiries and represent the complexity of production systems, so that users can tackle complex issues in service-based organizations. This process could be supported by some design and development protocols well established by scholars in this field. Facilitators can also deploy educational technologies such as digital enterprise resource planning boards with business intelligence, commonly by offering a gamified scenario comprising the real-world systems with learning goals. In comparison to other types of training environments, educational games always focuses on the edutainment effect, admittedly lacking meaningful activities from players and peculiar characteristics of the modelled system. Computer simulations as an approximation of the operation of processes provide an experimental learning platform and the player’s explicit control over a suitable type of subject matter [21]; however, these may fall short in interactivity, social relatedness, and retention. This section further provides a retrospective description of how the representation of complexity is being handled in gaming applications. 1.2.1 Medicine and health To improve task performance for the staff working on the ground, non- technical skills was first assessed for safety and protective measures by the European Civil Aviation Council in the 1980s [22], further being implemented for many industries inclusive of safety management training of marine transport, railways and healthcare, especially with the help of serious gaming and simulations. Non-technical skills training for expert performance in health were first approved in anaesthesia [23]. Since then the importance of non-technical skills for safe care delivery has been acknowledged worldwide. Not since the empirical validation has a technology so altered the nature of clinical training for healthcare
INTRODUCTION | 5 professionals as simulation-based training, shown in previous studies on the positive impact of reducing mortality and morbidity [24] [25]. From the 1990s, the effectiveness of the simulation-based instrument for non-technical skills training gained acceptance in a wide range of low- resource and high-risk settings. Amid this, scenarios with experimental setup have served ulterior goals comparted to case study methods regarding performance and strategy outcomes [26]. It is part of the mix of curriculums delivered at various medical educational levels for participants’ acquisitions of sense-making [27], communication, decision-making [28], planning and adaptation of work as central to coordination of care and operational resilience [29]. However, up until now these means have been used mostly for training teams in critical situations and that there are few applications of serious gaming applications for training the non-technical skills of day-to-day operations such as coordination of care or patient flow management. In addition to training effort, serious games could be an efficient technique for testing which models of management, leadership and organizations would apply for the work environment. 1.2.2 Logistics and transport management Logistics management research has inherited many serious game and simulation applications. They are highly motivating; on-line simulation games train management skills for complex chains, and they better facilitate the learning process than board games. As the most remarkable exercise in a classroom setting, the Beer Distribution Game, originally a board game, illustrates the system dynamics of food distribution systems [30], in particular, the “bullwhip” effect observed in real operations [31]. Later, the board game format evolved into its more recent screen-based business simulations [32]. Some researchers argued that the digital modality should be the prioritized media type, given the efficacy of all previous results, and aimed to enlighten educators about computer literary as it applies to digitalized serious games, finding them invariably advantageous for achieving the principal objective [33]. Simulation games offer a medium to counteract demand
6 | INTRODUCTION surges from player participation, a process in which the cognitive analysis of flows and resources is expected. Transportation management studies based on games and simulations consider virtual scenarios a safe container for experimentation. Several mature simulation games representing transportation business administration tackle on decision-making on a wide variety of operational issues. The EuroTruck Simulator is an entertainment game providing a learning platform in which the player starts as the owner of a freight forwarding agency [28]. A complete and functional transportation network is simulated in a realistic fashion. The usefulness and reliability of experiments using realistic simulator depend on how the players react to environmental changes. In the EuroTruck simulator applications, researchers consider the phenomenon of profound boredom, its value in self-realization and the experimental conditions of the player’s in-game existence, and its potential presence in all types of computer games [35]. 1.2.3 Energy management Energy management research applies simulation and serious games to adapt behaviours among individual citizens towards a sustainable energy consumption pattern among citizens. Specifically, in the nuclear energy franchise, the simulation game Energy City, which has both urban dynamics and entertainment components, was effective in promoting a positive perception of nuclear power [36]. The game was created to educate young teenagers on sustainable energy resources; in the game, the player aims to overcome the societal issues encountered by policy making and cultivate a responsible consumption and production portfolio designed in step-based, continuous decision-making processes and balancing economic, environmental and societal perspectives [37]. The pervasive and pedagogical benefits are harvested from the modelling and simulation of interactions between system components, similar to other energy gaming applications [38] . 1.2.4 Urban planning and management Urban planning and city management studies increasingly rely on participatory simulation and serious games to see on how individuals,
INTRODUCTION | 7 organizations and institutions could be affected by each other in a dynamic city environment. Specifically, the SimCity game characterizes on how the modelling and visualization of complex systems could support game-based comprehension of concepts and principles in teaching and learning scenarios [39]. This game is reported to find its success in the domains of political science [40], sociology [41] and geography [42]. The representation of business intelligence, system dynamics and organizational structures in a sophisticated simulation model enables the player to adopt a speculative view; indeed, the utilization of simulation and gaming applications is rooted in constructivist theory in which students acquire knowledge best through active learning [43] [44]. 1.2.4 Roadmap for serious gaming: summary The deployment of serious games in specific application areas is able to leverage the utility of the learning experience despite being challenged by the representation of complexity in simulated environments and the lack of concrete guidelines for game creation. As pointed out by a documentary from the Games and Learning Alliance, in tandem with the abovementioned advances in the field, it would be difficult to have one single design standard that would fit all except from the case of re-use [45]. However, game designers should focus on the holistic consideration of factors such as intended outcome, game element selection, modelling and simulation techniques, analytical methods and evaluation approaches. More importantly, context-dependent decision-makings should be evident in serious games for corporate training of soft skills [46]; in the case of accomplishing desirable objectives, they must achieve a balance between preserving realism while also not overwhelming participants, which would negatively affect their experience and flow. This necessary balance leads to requirements for game designers regarding the efficacy and effectiveness of game elements, which must be meaningful and relevant for participants. Understanding the effect of game elements for organizing the protagonists of real production systems would be a contribution toward meeting the “Representation of Complexity” challenge by 2030, which has been identified by the community as an important research direction.
8 | INTRODUCTION 1.3 Research questions As revealed by the retrospective of the field, there has been only limited investigation into the pertinent representation of production aspects in healthcare systems, as these have been overlooked in favour of mediating managerial skills in serious games. It requires specially designed artefacts in the game absent the representation of logistical aspects in general and underexplored utilization of gaming methods for addressing healthcare management issues in particular. The previous review reveals that much of the effort invested in serious gaming and simulations has been on behalf of urban planning, logistics and transport systems; gaming studies on the logistical problems of healthcare systems have been absent. With a slightly increasing allocation of research interests at this intersection, a few studies have started to use serious gaming methods. One main reason for this emerging trend is that most healthcare systems are confronting growing costs and resource consumption, making the improvement of efficiency in operative environments attractive. Even though the effect of game elements has not been fully elucidated, this issue has merit for further study, given that most healthcare management is confronted by a low-resource setting, overcrowding and operational inefficiency and imbalances. According to the gala roadmap report, the challenge could thus be outlined [45]: The challenge for the serious gaming community in addressing logistical challenges in healthcare systems is how to design, in the most efficient and useful manner, a gaming environment that can serve as a research platform for investigating the impacts of environmental changes. Gamification technologies could be applied on top of this environment to safeguard against production choices that do not meet the keenest requirements, while the outcome of play could be behavioural models estimated to offer the promise of reducing imbalances and inefficiencies. It is possible to meet this goal while respecting the statutory rules of the real system by the progressive introduction of pertinent, specially designed game elements.
INTRODUCTION | 9 This study aimed to explore game element design and to understand its acceptance and its usefulness for improving healthcare logistics management subjects to operational conditions and patient flow characteristics. Extensive previous literature discusses using simulation and gaming for training coordination and team-working skills in medicine and nursing, yet the potential to help players approach the logistical aspects of healthcare and to mediate managerial skills remains unexplored; this could be a denial of the essential logistics management skills that are critical for sustaining organizational resilience in limited resource healthcare settings. The practical aspect of this study aims to be useful to the corporate training communities by demonstrating how to design, develop and deploy a serious game for training non-technical skills in service-based organizations, elaborated by the following core research questions. 1. What is the state-of-art of serious gaming and simulations for logistical aspects in healthcare? 2. How should serious games be designed for training resource management skills in emergency medicine? 3. In what ways does the use of scoring-based mechanics and modalities influence game experience and learning behaviours? 4. What do the behavioural models of production choices in simulated environments signify for serious game design? 5. How could outcomes of play enrich simulation-based predictions? 1.4 Case study description The thesis utilizes real data from an ED and behavioural data from a set of game-based practices, with all needed approvals having been obtained. The paediatric ED is part of the children’s hospital, and it receives patients with complex health problems and critical illnesses from a large spatially diverse area. In 2017 alone, fifty-three thousand visits with over one hundred primary causes (fever, headache, etc.) were recorded. Due to the availability of primary care facilities that are open 24/7 and because a referral from primary care is not required,
10 | INTRODUCTION many patients choose to come directly to hospital-based EDs. Individual arrival time, length of stay, wait time before seeing doctors and priorities are also collected from the data. In addition to patient flow data, configurations of human resources, floorplans and structural care pathways were documented based on multiple visits to the paediatric ED in 2017 and 2018. The medical activities frequently executed for child patients, their time horizons and the required health human resources are drafted with the help of consultation with ED employees via a thorough, iterative process. This information is used to create unique patient profiles in a simulated environment. Overall, the reason for using actual data from multiple sources is to create a serious game capable of representing complexity. Through this effort, it is believed that participants in the serious game will be directly connected to a highly realistic operating environment. The serious game therefore could serve as a living lab, offering ex ante assessments of healthcare production in reality. The second dataset utilized in this work is behavioural, environmental and survey data collected from voluntary participants with management and engineering education backgrounds in game-based learning sessions. At the time the game sessions were implemented, all participants were involved in education programs. The behavioural data captures learning engagement attributes and production decisions as the players proceed in the game. Survey data based on the Core and the Social Presence Modules of the GEQ were collected. The modules comprise multiple dimensions and a rich set of question items; responses are based on a Likert scale. The robust design of the questionnaire guarantees a holistic evaluation of the game experience. These quantitative measurements enable the assessment of the gameplay experience and meaningfulness considering different aspects. Finally, environmental data on operative metrics and score updates were logged and used for modelling and analysis. The gameplay took place over a time period of nine months starting in August 2019. In total, thirty-six students joined the gameplay in different modalities. Board game play was first implemented, followed by a two-week break. After the break, the participants played the digital version. This experimental setup minimizes any subjective
INTRODUCTION | 11 bias that could be engendered by different individuals. Meanwhile, this study deploys a relevantly sufficient sample size and rich choice situations to record heterogeneous preferences. 1.5 Research objectives Research objective 1: to examine the simulation technologies that could be used to foster understanding of various situations and decision- making processes in healthcare logistics. (Paper I) In Paper I, using simulation as a means for training was the specific lens through which the literature was understood. It focuses on the synthesis of simulation and gaming applications for a wide variety of healthcare logistics topics based on a query-based search strategy in the Web of Science Core Collection, ACM digital library, and JSTOR databases. Common logistical aspects for healthcare logistics are summarized. After the literature review, event-based simulation and systems dynamics were identified as the main modelling tools. Although there are fewer contributions in this field than in event and systems dynamic simulations, agent-based simulation has received stable attention in recent years. However, gaming simulations are underexplored for addressing logistical problems, hindering the efforts to understand how games could be designed and used. Event-based simulation remains an understudied research strategy in this field, which indicates a risk that the full potential of gaming methods that have been demonstrated successful in other industrial operation sectors is not being deployed. Research objective 2: to construct a serious game based on a simulation model of healthcare production that emulates the reciprocal relationship between the work system mechanism and patient inflow. (Paper II) Paper II aims to develop a simulation model based on real data from the studied ED. Game mechanics that are closely connected to the simulated operative environment are selected, discussed and compared with previous studies. Paper III partially addresses serious game design. Because this represents an attempt to design games in such a new domain, the effect of the modality is not clear. Therefore, a serious
12 | INTRODUCTION game is established in different modalities by transferring the simulation model into a board game and a multiplayer online digital game that is supported by game elements. In particular, a serious game has been developed to incorporate a scoring-based element that tracks the participant with regard to logistical aspects of healthcare logistics. Research objective 3: to understand the learning behaviour transitions subject to impacts from the scoring-based system and the game experience as a whole. (Paper III) Paper III adopts quantitative approaches to analyse the influence of the scoring-based system and the general patterns of learning behaviours. Learning engagement attributes are particularly defined for this study, bearing in mind the expected actions from players in such a production type of game. User data are collected via in-game probes, and hence after analysis, using a lag-sequence model and regression analysis. The game experience is understood by the Core and Social Presence Modules of the GEQ. The questionnaire scores are compared with those of serious games recently applied in healthcare-related situations. Research objective 4: to estimate a choice model in face of the change in environmental parameters and the stimuli from the scoring-based system. (Paper IV) Paper IV, based on the discrete choice theory made accessible by game elements, constructs a nested logit model to explore the effectiveness of the game elements. The effectiveness is quantified, which can be helpful for guiding serious game design or for introducing gamification frameworks in real working environments in favour of certain production choices. Research objective 5: to provide an ex ante assessment of operative metrics (Paper II and Paper IV) Although the above-mentioned research questions will be covered in this work, it is valuable to explore technological forecasting based on simulation and gaming. The resultant findings in Papers II and IV illustrate the potential of serious gaming for guiding real production.
14 | INTRODUCTION be mediated, and a usability study focused on advantages and weaknesses of gaming approaches. While healthcare logistics has been defined in various ways by researchers, in this thesis, we define it as “operational handling for the delivery of care, including its supportive services, from origination to recipient.” For patient-centred care, healthcare logistics relate to patient flows through the healthcare system or hospitals and require a coordinated effort from the provider side. In this context, the quality, safety, and efficiency of services for patients are keywords that result in work system mechanisms and team processes as preliminary factors. Based on the design approach by Klevers el al. [47], the serious game integrates a simulation model of the production system in paediatric emergency medicine to provide a risk-free operative environment. The represented processes are written in BPMN notations to be generic and playable, thus making it convenient to reproduce the work system through an industrial simulation fashion, namely, a computer model for creating virtual production systems. The basic entities of healthcare logistics operations and their mechanisms are integrated into the serious game, including shifts, organizational structures and patient arrival processes. An agent-based and discrete-event approach is adapted for the representation of patients and workers. A gamification design based on a scoring mechanism is applied to inform the importance of logistical processes in the delivery of healthcare and to steer behavioural changes that could be useful for eliminating access blocks and overcrowding in healthcare. Real-world processes in logistics are represented, with the intention of capturing the main actors in service delivery, their interactions with patient flows and the work environment. The serious game is used to identify successful coordination strategies, prior to which, score-based gamification is applied to balance role plays in parallel functioning units. In-game production choices are analysed as decision-making processes in which individual participants optimize and plan based on their preferences, background and understanding of the system. How players
INTRODUCTION | 15 make their choice sets and choose between resource management strategy alternatives is imitated by a production model, along with patients’ reception of service from a given state to their discharge. The evaluation of structured model parameters is based on user-generated data and content from non-intrusive data tracking accompanied by other approaches, such as behaviour coding. Attention is given to the choice- set available to the serious game participants, after which structured knowledge from gaming is available by applying user modelling methods. The research contributions of this work are in the body of knowledge of serious games and decision-making science, specifically in using quantitative technologies to inform decision-making at individual and aggregate levels. The main contribution to the serious game field is the exploration and empirical study of the systemization of game elements for mediating managerial skills in healthcare production, the evaluation of efficacy and effectiveness and the reflection on lessons learned from the process. Serious game design is expected to be auditable and transferable to similar contexts: 1. Representation of complexity based on a multi-method simulation approach for modelling an ED. 2. Development of a serious game based on elements closely connected to the logistical aspects of healthcare management and operations. 3. Investigation of the impact of game elements on production decisions based on individual choice modelling. From the methodological point of view, some empirical advances have been made to improve operations management by providing the healthcare context: 1. Extension of the behavioural choice model to a service provision context potentially affected by gamification features and game dynamics as psychological and environmental stimuli, respectively. 2. Evaluation of player experience for a non-recreational game in different modalities based on the GEQ.
16 | INTRODUCTION 3. Development of a serious game methodology for the technological forecasting of operational metrics for logistics and production. Examples of potential applications include organizational resilience analysis, service coordination, effects of work system changes, assessment of operational policies as strategies, patient flow analysis, and the active learning of non-technical skills. 1.7 Thesis outline The remainder of this work consists of four chapters, as outlined in Fig. 3. In the next section, recent approaches and technologies at the intersection of gaming, simulation and behavioural science are revisited. Chapter three delivers a research summary based on four attached articles. The significance of the findings is elucidated by comparing the research findings to previous works in the field, bearing in mind limitations and future perspectives. Last but not least, the articles are attached as appendix.
18 | METHODOLOGICAL REVIEW 2. Methodological review This chapter revolves around the primary methods in the gaming research pipeline used by research articles to draw conclusions regarding the effectiveness of design, experience, effects on learning, user modelling and predictions. The applications relevant to gaming design and learning effects on management science that have been presented in the previous chapters offer the promise of integrating the advanced state of complexity into gaming media. Simulation models of systemic features based on reality are a highly motivating context in which to investigate learning behaviours and decision-making and to reflect upon whether mediation of the very much needed knowledge, skills, and attitudes as desirable objectives has been met. 2.1 Gaming and simulation From previous chapters, we know that simulation-based learning activities with high realism and fidelity allow participants to embrace complex concepts and solve complex problems. However, for operational situations, there are still no training and learning platforms that can be used to learn skills in typical daily management and logistical decisions. In order to create simulations and games that are valuable for training in non-technical skills [48], it is important to know which types of problems should be addressed by which types of simulations and games, an important guideline for a person who works as a nurse, doctor or manager in the hospital. To design meaningful and relevant scenarios for participants in organizational settings, it is also necessary to incorporate social dynamics. Before venturing further into the literature to explore what different types of games are used for, it is useful to consider a few definitions from the glossary of terms used in connection to serious games. At times, the terms are treated interchangeably, leading to authors writing one thing but actually meaning something different. For example, not all serious games are considered gaming simulations, which mainly concern the representation of complexity. This section is thus an opportunity to examine the landscape and emphasize the interests involved in gaming. Regarding this issue, pure computer simulations, serious games, business
METHODOLOGICAL REVIEW | 19 simulations and social simulations can be identified from the state-of- the-art through a synthesis of the literature and of recent illustrative examples, regardless of which real systems are being represented. Here, we define gaming in this work as an application-oriented interactive approach destined for serious purposes. As suggested by Per Backlund, serious games are defined as the application of gaming technology, processes, and design to solve the problems faced by businesses and other organizations [49]. By providing the problem- solving focus for organizational issues, serious games represent the main type of gaming media in every level of application. The classic serious games in teaching include the Harvard Business School Management Simulation, which allows teams to practice decision-making skills in all areas of business and which has a strong connection with production management teaching and learning [50]. Recent examples with clinical benefits are evidenced by the adoption of serious gaming in the medical education domain, raising the possibility of teaching declarative knowledge and training for specific scenarios that are hard to reproduce in the daily curriculum [51]. In the following session, typical contributions are identified from high-profile journals in the field of simulation, gaming and management science. Afterwards, the characteristics of the different gaming simulation types are summarized. Formerly, computer simulations referred to interactive techniques based on scenarios and environmental changes in military training situations. More recently, they also model real industrial systems with states and transitions [52], providing the ability to study the impacts of different scenarios in a ‘safe container’. Computer simulations in management studies use discrete-event simulation, systems dynamics and agent- based simulation paradigms, which simulate both technical and social aspects of complex systems and represent validity in a collective manner [53]. Contemporary simulation studies tackle all areas of management studies, including logistics [54], transportation [55], and healthcare delivery [56]. The methodological advances include the multi-method simulation modelling of complex processes [57] and its integration with
20 | METHODOLOGICAL REVIEW gaming methods [58] that enrich computational models and prediction results. Business simulations are a sequential decision-making exercise structured around business operation models, in which participants assume the responsibility for managing simulated operations [59]; they play an important role in extending the case study teaching method to feature the projection of players into the game [60]. An early example was the “Top Management Decision Simulation”, after which the majority of US business schools used gaming techniques in teaching [61]. Business simulations characterize a type of gaming media that can address strategic and operational decision-making. Recent business simulations are relied upon in corporate training to understand fundamental economic and operational theories for administering service-based organizations [62] [63]. Social simulations unravel issues in sociology via computer simulations. Researchers have conducted simulation experiments to replicate human behavioural processes and multi-agent systems. Brown constructed an agent-based mixed logit model of vehicle choice for the technological forecasting of consumer preferences and their impacts on electronic vehicle market segmentations [64]. Rising up to the challenge of ageing societies, the spatial planning of day-care centres through the elicitation of residents’ socio-economic mechanisms and operating rules has been enabled by agent-based modelling on the NetLogo platform [65]. Irrational and subjective behaviours in crisis situations can be represented by modelling and simulation based on interview statements, potentially eliminating the underestimation of dangers and/or abilities [66]. As illustrated in Table 1, these games are instrumented to not only focus on the activation of learning via user-centred content delivery but also to incorporate multiplayer interactions. Although business simulations characterize the classic teaching methods in operations management, serious games hold significant promise for benefitting decision-making skills training on tactical and clinical levels.
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