Review of 1,127 Studies Maps Design Methods to Healthcare Levels

A systematic review published in BMC Health Services Research screened 1,752 papers and synthesised 32 reviews covering 1,127 individual studies to answer a question most service teams still settle by habit: which systems engineering or design method fits which healthcare problem.

The review, led by Yuan Yin, Thomas Richards, Ji Han and Saeema Ahmed-Kristensen, ran its search on 4 November 2024 across eleven databases, including Embase, Medline, PsycInfo, CINAHL, SCOPUS and Web of Science. It covered reviews published in the previous five years and produced a conceptual framework that maps methodologies onto the three tiers at which healthcare operates: the micro level of the individual patient, the meso level of the service, and the macro level of the system as a whole.

For interface and service designers, the most actionable finding sits at the micro level. The synthesis found that user-centred design and co-design approaches enable more inclusive and patient-responsive service frameworks, and work best for patient-level challenges: usability, engagement and experiential outcomes. The authors add a caveat that practitioners will welcome. Effective co-design, they conclude, does not necessarily require following a formal design thinking process. The rigidity of the process matters less than the depth of user engagement itself.

What does the framework change for method selection?

At the macro level, the toolkit differs. System-level transformation demands systems thinking combined with structured stakeholder engagement to manage complexity and support sustainable organisational and policy change. Systems approaches, the review found, have provided tools for managing complexity at policy and organisational levels more broadly. The framework makes this tiering explicit rather than leaving teams to infer it.

The authors emphasise that sub-methodologies within the systems engineering family differ in meaningful ways, including:

• their degree of structure,
• the depth of user engagement they require,
• the level of the system they intervene upon.

These distinctions, they argue, underscore the importance of aligning methodological choice with healthcare context and stakeholder needs.

The review also confirms where adoption stands. Systems engineering and design approaches are increasingly used in healthcare service contexts, with service design, service improvement and service development emerging as the most common areas of focus. According to the review, these approaches show promise towards increasing efficiency and reducing costs for health systems while preserving patient experience and health outcomes. Their application across health systems has so far remained limited.

How rigorous is the evidence base?

The methodological scope is worth noting. The team restricted inclusion to reviews applying systems engineering methodologies at a systems level in healthcare, covering quantitative and qualitative secondary studies: reviews, systematic reviews, overviews, meta-analyses and meta-syntheses. Primary studies were excluded, as were interventions using systems engineering methods toward specific products such as healthcare apps rather than services or systems themselves. A framework synthesis methodology extracted data according to a framework developed a priori, and the risk-of-bias or quality assessment tools used in each included review were catalogued.

Three gaps temper the conclusions:

• Outcome standardisation remains weak, meaning studies rarely measure success in comparable ways.
• Implementation evaluation is underdeveloped.
• Adaptation of these methods for low-resource or culturally diverse settings remains limited.

As a review of reviews, the study synthesises secondary evidence rather than generating new patient outcome data, and its conclusions reflect the scope of the 32 included reviews and the 1,127 studies within them.

The authors position the framework as a foundation for future work — a decision aid for healthcare leaders and researchers choosing an approach for a given scenario, and a baseline against which the field can close its gaps in outcome standardisation, implementation evaluation and adaptation across diverse settings.