All over the world we are seeing the growing importance of technology in healthcare organizations, the changing ways in which people interact and the rise of the use of gaming. At this moment healthcare institutions are only starting to use serious or applied games. The current market of applied gaming is estimated at $10 billion worldwide. Analysts predict that this market will boom, and similar assumptions can be made with regards to the healthcare component of this market. Within 5 years it could exceed the entertainment game market, which is estimated at $70 billion. Our forecast is that within 5 years the use and development of applied games will have a role in our daily lives and the way we organize healthcare that will be similar to the role social media has today.
Gaming can be seen as the next step in the application of information technology to healthcare, because gaming improves interaction and has a direct impact on human behavior. “By the age of 21, the average young American has spent somewhere between two and three thousand hours reading books and ten thousand hours on playing computer and video games” (McGonigal, 2011). The younger generations are no longer learning and working in the same way as we do, through books. They are not only playing games for fun and entertainment, but using gaming technology in many ways, which is driving this emerging market. This is and can also be the case for healthcare professionals and patients.
This article introduces the Game Maturity Model for healthcare organizations, which can be seen as an extension and elaboration of the general Game Maturity Model that was introduced by KPMG in 2013. In the current healthcare market, organizations constantly face more and more pressure to gain and retain a competitive advantage, identify ways to cut costs, improve quality and reduce (the risk of) errors. Gamification and a framework tailored to healthcare institutions can help organizations to address and resolve these problems. We have adapted the Game Maturity Model to help healthcare organizations introduce and improve their use of gaming. This adapted Game Maturity Model can help healthcare organizations quickly determine their target position and develop a roadmap for moving from their current to their target position.
First, the meaning of the term “applied or serious games” is briefly discussed, after which the theory of maturity models is presented. Secondly, this article shows the design of the Game Maturity Model and the way it can be used by healthcare organizations. Lastly, two case studies of health games are presented as examples of the successful use of games in healthcare.
Applied games and gamification
Serious or applied games are models or simulations of real-world events or processes, designed for the purposes of problem-solving and learning. Although applied or serious games are entertaining, their main purpose, in our opinion, is to change the behavior of organizations and human beings (such as patients, medical students or professionals). For the purpose of this article we use the term “applied gaming” instead of “serious gaming.” The reason is that, in our opinion, “serious gaming” is a contradiction in terms. “Serious” typically means no fun at all. Fun is a characteristic of all games, although some games have serious applications. “Serious gaming” also implies that some games are not serious. This is not the case.
Applied games are very often used in the context of gamification. Gamification is the use of game mechanics and game design in non-game scenarios (such as healthcare environments) in order to change behaviors and increase motivation to change. Typically, gamification includes developing processes and applications to first entice users to participate, then engage them so they will share and interact in an activity or community. Gamification is a method for engaging medical personnel and clients in desired behaviors, while their involvement and pursuit of these behaviors works to solve (their) problems. Essentially, it takes advantage of humans’ psychological predisposition to engage in gaming.
Gamification applications can have a wide variety of possible objectives, areas of application, complexity and levels of voluntariness, depending on the goal of the game. Internal gamification, for instance, focuses on processes inside the organization, such as training medical students to perform complex diagnosis and treatment. Internal gamification focuses on finding fun in the things an employee has to do, to increase motivation and performance. Fun is a result of learning, and learning can be seen as pattern recognition. By recognizing patterns, our brain produces endorphins and dopamine, and we experience ”fun.” External gamification focuses on things outside the organization, such as patient-related gamification. The focus here is trying to enhance the patient’s user experience. Ideally, the end goal of gamification is incorporating games into the entire ecosystem of the health organization. Some gaming applications may incorporate multiple complex tasks, such as a game that helps surgeons practice surgeries, but may also be related to more common tasks, such as compliance training. For all these processes, gamification can be applied effectively.
Using games or applying game elements is not a new concept. Military officers have been using war games in order to train strategic skills for a long time. Also, there are a lot of games focused on policy and management issues. More focused sub-groups have appeared, including Games for Change which focuses on social issues and social change, and Games for Health which addresses healthcare applications (Wikipedia, 2013).
Current gamification applications in healthcare often focus either on treatment for patients or on training for medical students and personnel (possibly including professionals). There are very advanced forms of gamification that stretch our imagination. For example, there are games that aim at fighting cancer or changing the way we build cities. There are prominent gamification techniques such as achievement badges, achievement levels, leader boards, progress bars (indicating how far the user is from completing the task), virtual currency, systems for awarding and exchanging, challenges between users, etc. (Wikipedia, 2013).
Table 1. General gamification applications & techniques
|Common Gamification Applications||Common Gamification Techniques|
|Project management||Leader boards|
|Employee reward and recognition programs||Progress bars|
|Knowledge collaboration||Virtual currencies|
|Innovation management||System for awarding and exchanging|
|Marketing and customer interaction||Challenges between users|
Table 1. General gamification applications & techniques
A maturity model basically indicates what level an organization is at within a specific domain. “Maturity models are used as an evaluative and comparative basis for improvement in order to derive an informed approach for increasing capability of a specific domain within the organization” (De Bruin & Freeze, 2005). A maturity model evaluates an organization only in one specific domain, and ranks the organization according to the levels of maturity defined. The scope of a maturity model includes the norms and goals in the entity being mapped by the model. Often these are organizational entities. The model presented in this article has been adapted to gaming for healthcare institutions.
As outlined, maturity models typically include a sequence of levels (or stages) that form an anticipated, desired, or logical path from an initial state to maturity. Basically, maturity models consist of several maturity levels or stages, with a typical evolutionary path through these stages. The first stage, normally called the bottom or initial stage, indicates an organization (or process) with few capabilities in the domain the model is covering. Low maturity can in general be described as uncoordinated, reactive, internally focused, ineffectively resourced, naïve and static. In contrast, the highest stage represents an organization with total maturity in the specific domain. High maturity can be described as having an organization-wide focus, proactive innovation, efficient resourcing and comprehensive understanding. A maturity model functions as a scale for assessing an organization’s position on the evolution path. Often, these models provide characteristics that need to be in place for an organization to be described as being at a particular maturity level. A maturity model provides different characteristics for each specific level. In between the initial and mature phase are growth phases. It is important that these phases logically follow.
In management, maturity models have proven to be a helpful instrument, because these models allow for better positioning of the organization and help to stimulate continuous improvement. A maturity model can help health organizations to quickly assess their current position and develop a roadmap for improving their domain position from the current to the desired level.
Maturity models and applied gaming
We saw that there was a need for a maturity model that focuses on the subject of applied gaming. The need for a game maturity model that addresses gaming is growing rapidly as organizations relentlessly step up the pace and size of investments in applied games, but lack experience in organizing their gaming capability. As a result, the dependence on reliable, continuous and competitive applied games is mounting. We predict that within 5 years healthcare organizations will be coming under increasing pressure to achieve above-average performance using applied games, as they are a cost-effective method to train and maintain the skills of students and personnel (even professionals). The various stakeholders (including top management and leading medical professionals insist on direct, increasingly transparent insight into whether applied games and incorporating these games into institutional operations yields added value that justifies the investment required.
In developing a maturity model, we compared the model with other relevant maturity models in terms of the pre-determined problem, target and demand. A good example of the concept of measuring the maturity of an organization was introduced in 1991 with the Capability Maturity Model (CMM) by Carnegie Mellon University. This widely used model focuses on the domain software development and maintenance of an organization. The model pinpoints what level an organization’s software development capability is at. The model distinguishes five levels: the initial, repeatable, defined, managed and optimizing levels (see Figure 1).
Figure 1. The Capability Maturity Model [Klik op de afbeelding voor een grotere afbeelding]
The Game Maturity Model
As outlined, gamification can have either or both an internal or external focus. An organization can implement several focused gaming solutions to discrete problems, or can integrate gamification into its overall strategy. Games can focus on general training or behavioral change, and can even teach medical knowledge and skills. Each of these approaches helps identify the maturity of an organization in regards to gamification. We believe that maturity modeling can help identify the position of a healthcare institution in regard to gamification and help the organization identify steps to proceed to the next maturity level. For instance, gamification can be applied to make a task more fun for employees, without necessarily achieving benefits like behavioral change or learning. This would indicate a lower level of maturity in comparison to an organization that implemented gamification in its organization while achieving these benefits. In the more mature organization, gamification contributes to actual healthcare execution.
The model distinguishes four perspectives, each with five maturity levels (see Figure 2). We designed the model with five levels, because this is in line with the CMM model, which is the basis of many maturity models. The four perspectives are related to, first, the value that is produced with gamification; second, the process that is in place in the organization to support the gamification strategy; third, the company-wide coverage that is applied to gamification, and, fourth, the technology that is used for gamification to be a success. We propose that organizations rank themselves according to each of the four perspectives in order to assess the level of gamification and the contribution of gamification to their strategic goals.
Figure 2. The Game Maturity Model [Klik op de afbeelding voor een grotere afbeelding]
The first perspective of the model is related to the value generated through gamification.
- Non-existent – No value seen in using games, or no gamification in place.
- Pleasure – Using games for pleasure but not yet for results. Games have no real purpose.
- Passion – Games promote flow and engagement, and stimulate learning and healthcare simulation.
- Purpose – The goal is to advance and innovate using games. Actual healthcare execution and treatments are done through gamified processes.
- Healthcare profit – Quality of healthcare is increased and costs are lowered due to use of gamification.
Clearly, the lowest level of value generated through gamification applies to organizations where there is no gamification at all. Healthcare organizations that do not use game techniques in their treatments or services would be scored in this level.
The next level applies to organizations that use games solely for pleasure, and not yet for actual healthcare results. The benefit is short-term and focused on getting a dopamine effect (a rush). These games do not have a real business purpose (yet), as in the case where an organization lets its employees or patients play games just for entertainment, without expecting results or improvements from the activity.
In the next level, called “passion”, flow and engagement are central. A healthcare organization that is scored in this level uses game techniques to improve their employees or patients through a certain activity, encouraging them to spend more time than they would have previously spent on this activity. An organization that uses gaming techniques for learning and healthcare simulation would be scored in this level. When people are in the state of “flow” they can concentrate on a subject intensely, for a long time, without distraction (Hsieh, 2010). Gaming techniques can enhance this state, and can therefore help organizations to engage their customers or teach their employees.
The fourth level, “purpose” applies where there is a higher purpose to playing games. It is part of achieving something bigger than presently exists. For instance, the gaming relates to strategic business goals, such as a hospital that uses game techniques to change the mindset of its employees, or a game that can cure or save the lives of patients.
The last maturity level, “healthcare profit,” describes game initiatives that actually succeed in meeting this higher purpose. You can measure and validate the outcome. This can be financial profit or non-monetary benefit: for example, improving the quality of life for a patient with Parkinson’s disease; or improving compliance with regulations in a financial institution thanks to behavioral change achieved by playing a “Compliance Game.”
The second perspective of the Game Maturity Model is related to the process that is in place to support gamification.
- Ad hoc – Gamification processes are unpredictable, poorly controlled and reactive.
- Repeatable – Processes are matched to projects and are often reactive.
- Defined – Gamification processes are developed organization-wide and are proactive.
- Managed – The gamification process is measured and controlled.
- Optimized – There is a focus on continuous monitoring and improvement.
This “process” perspective is marked by evolutionary levels that are adopted from the CMM model (Carnegie Mellon University, 1991). The difference is that the Game Maturity Model only focuses on the processes in place to support gamification. In the initial “ad hoc” level, gamification processes are unpredictable, one-off, poorly controlled and reactive. Problems in the game processes are only solved after they appear.
In the next level, repeatable processes for gamification projects are developed, but the organization still acts reactively towards gamification. It is an improvement over the lower level in that knowledge already gained will not be lost, at least because a project-management capability has been developed.
In the “defined” level, a healthcare organization starts to act proactively towards gamification processes. Gamification processes are well known throughout the organization.
In the fourth level, the gamification processes are structured as part of the healthcare procedures, so the outcomes of gamification initiatives are measured and controlled.
In the highest level of this perspective, “optimized” processes around gamification are organized, managed and well known. The focus has shifted towards continuous improvements by empowering employees of an organization to generate long-term benefits through applying processes around gamification.
The third perspective of the model is related to coverage, or the ways in which gamification and games are applied by organizations.
- None – No gamification in place.
- Individual – Gamification is applied by individuals.
- Entity – Gamification is applied within functional groups or healthcare departments.
- Institution – Gamification is applied across the healthcare level.
- Ecosystem – Gamification is applied in complete horizontal and vertical integration throughout the ecosystem of the users and providers of healthcare.
At the initial level of this perspective, gamification is non-existing.
The second level indicates that some individuals within the organization apply gaming techniques, but there is no widespread implementation of games throughout the organization.
The next level, “entity,” indicates that games are used by some groups or departments. Currently, education and training departments in healthcare institutions are the early adopters of gamification techniques. For instance, healthcare educators may use games to simulate emergency situations; they can increase patient safety by providing students and healthcare professionals with a safe learning environment to practice emergency medical skills, as in abcdeSIM created at Erasmus University Medical Centre (abcdeSIM, 2012). Another example of this outside the healthcare world is Starbucks, which offers a mobile app having a rewards section in which game elements are embedded (Starbucks, 2013). In such a case gamification has been applied by the marketing department, but it may not have spread throughout other parts of the organization.
At the fourth level, the application of games is spread throughout the whole institution. Gamification is an important topic on the board level, and is used in many different ways (e.g., education and training purposes, patient interaction and healthcare treatments).
The highest level is where the whole ecosystem of which the healthcare institution is a part is involved in the application of games. Not only employees of the health organization itself, but also patients, suppliers and other stakeholders are involved in game techniques. Gamification is applied externally. An example is the airline KLM, which involves customers of their loyalty program in optimizing their company processes through playing a game called “Aviation Empire” (KLM, 2013).
The fourth perspective of the model is related to the different types of games that are used by organizations.
- Off-line – Non-internet, non-network components, such as traditional board games, are used.
- Single-player – Online single-player techniques are used.
- Multi-player – Online multi-player techniques are used.
- Group playing – Online group playing techniques are used.
- MMO – Mass multi-player techniques are used.
There are many types of games and many ways to categorize them. We have chosen the types described above as benchmarks for this categorization because they chart an evolutionary development. As the levels rise, techniques enable the game to be played by more and more users. In the first level, traditional off-line games are played within an organization. In many cases these are traditional board games. A healthcare organization at this level sees the benefits of games and therefore plays games, but does not have the technology in-house to support this. Board games or paper-based games (e.g., traditional management games) are played off-line and without the use of technology. It is important to mention that there is nothing wrong with a board game or any other off-line game. These kinds of games have proven to be very effective, and they are still effective in many ways. In the maturity model our focus is on digital games.
In the next level “single-player” games are digital and realized through the use of technology. In this level an organization uses online single-player techniques to support its gamification strategy. A single-player game is a game where input from only one player is expected and no collaboration between other players is in place, as there are no other players who play the game in the same environment.
In the next level of maturity, an organization would use multi-player game techniques. A multi-player game is designed to let more than one player play in the same game environment at the same time. Other players in the game are real-life people: for instance, healthcare co-workers. This enhances interaction between the players. Interaction could take the form of partnership, competition or collaboration. All are relevant if you look at the real-life situation an organization and its employees are in daily. Such a multi-player game can help an organization understand the social context in which situations happen.
The fourth level is a type of group game: specific groups of people are playing the game together in a virtual environment. The Dutch Ministry of Defense, for example, is using this kind of game to train groups of a hundred or more soldiers to prepare them for their international missions.
The highest level of maturity is applicable when we talk about mass multi-player online games. These are very often web browser or console based, in which a very large number of players interact with one another within a virtual game world. The most famous and popular pure entertainment MMO-RPG game is “World of Warcraft,” with more than 8 million players. In an MMO game the players are all real people who interact in the online game environment. Mass multi-player online games are distinguished from single-player and multi-player games by the number of players. When the player is offline the game environment still exists, and it evolves as other game players continue to play in the online environment. The development of an MMO-game is very time-consuming and, in many cases, expensive. Massive multi-player online games are building the ultimate collaboration. They can also generate insights by making use of the behavior of real-life people who play the game. Such a game could, for instance, be used to test a new healthcare campaign to prevent obesity. This type of game enables healthcare organizations to experiment with new strategies in a close-to-real-life setting. Promoting collaboration can result in new and innovative solutions to problems. “Very big games represent the future of collaboration. They are the best solution we have for solving the most complex problems of our time. They are giving more people than ever before in human history the opportunity to do work that really matters, and to participate directly in changing the whole world” (McGonigal, 2011).
There are many examples of applied games in healthcare. For the sake of this article we have picked two examples to demonstrate the strength of the Game Maturity Model in the healthcare domain:
Figure 3 abcdeSIM [Klik op de afbeelding voor een grotere afbeelding]
Figure 4 Geriatrix [Klik op de afbeelding voor een grotere afbeelding]
|abcdeSIM by Erasmus University Medical Centre (2012)||Geriatrix by Radboud University (2013)|
|Perspective||The goal behind the development of the abcdeSIM emergency medical simulation program is to increase patient safety by providing students and healthcare professionals with a safe learning environment where they can practice emergency medical skills without any risk to patient health. AbcdeSIM is based on a high-fidelity physiological model that contains more than 200 parameters for circulation, respiration and consciousness. This model creates a very realistic and immersive experience in which the trainees can see the direct results of their chosen diagnostics and treatment.||In this game medical students practice providing care to elderly patients. Complex medical reasoning is taught to the students by putting them in a situation where they are the “real” doctors. Students are shown patient cases and have to choose what steps to take. Students are given points based on three factors: patient preferences, costs and medical usefulness.|
|Value||The game is ranked at the levels both of “purpose” and “healthcare profit.” abcdeSIM increases the knowledge and skills of emergency medicine through simulation of various types of acute injuries while at the same time taking the risk of errors involved in real-life cases out of the equation. Moving beyond achieving its institutional purpose, abcdeSIM also reduces the cost of training by partially replacing lengthy face-to-face training sessions with virtual training online, which does not require instructors. Preliminary research results show improved emergency skills among the trainees.||The game can be categorized at the level of “purpose” as the students learn reasoning that is hard to learn out of a book. In a book, students learn the medical protocol, but in the game ethical choices are also important. The game can develop these behaviors. Furthermore, the game can be categorized within the category “pleasure” as the game makes the course of elder care more fun.|
|Process||Gaming is “optimized” within the Erasmus University Medical Centre. A spin-off company has been created to manage the development and usage of applied games both within the hospital and by third parties. The game is continuously improved by introducing additional patient scenarios. The usage of applied games influences the training process positively by reducing time and financial expenses||Currently the game is still played on an ad hoc basis. The students play three cases in one course, but do not use this game during other courses in medical school. The game does give students a platform where they can add their own developed patient cases. This platform could be used by other medical school curricula as well. The basics could be easily copied. The goal is to make a licensing system behind the game for others to use.|
|Coverage||The scope of coverage is wide, encompassing the entire ecosystem. Over 1,000 doctors in The Netherlands are currently using the abcdeSIM game. At the moment, abcdeSIM is being introduced abroad with contracts in medical institutions in two other countries. Erasmus University Medical Centre is investigating the introduction of applied gaming outside the domain of acute healthcare, in various other academic fields at Erasmus University.||The game is limited in its scope of coverage, limited to the geriatric care program of Radboud University. Around 200-300 students play the game each year. There is potential for greater coverage throughout this and other healthcare institutions or even throughout the larger ecosystem, as the game can be easily copied to other courses at Radboud or other universities.|
|Type||The game uses single-player techniques and some multi-player features. The simulated treatments are single-player challenges. However, game competitions have been held at four academic conferences between doctors and nurses, which is a multi-player characteristic. These competitions were very engaging and enjoyed by the players.||The game uses single-player techniques. Each student plays the game in a solitary environment and cannot affect the games played by other users. There are no real plans to change this at this time. The first goal is to implement the game at other universities and in other courses, so as to change the way students think and behave.|
In implementing games in a healthcare environment, the Game Maturity Model proves to be an excellent tool. It links the vision and strategic plan into concrete objectives for applying gamification in healthcare situations and processes. In our opinion these objectives must be organized along the lines of the four different perspectives: value, process, coverage and type.
The essence of applying games in organizations is to follow calculated steps that correspond to the growth in the organization’s maturity. As an organization becomes more mature, the maturity levels go up and a better equilibrium is established between the different perspectives. In addition, the integration throughout the organization as a whole becomes clear. Healthcare institutions are ideally suited to maximize healthcare training and delivery with the use of gamification, like the abcdeSIM case study shows.
During the first growth level, gamification is managed in the short-term, mostly by individual front runners. In the second and third levels, more emphasis is placed on the strategy of how to apply games specific to a healthcare institution. The focus, however, will be internally driven. The relationship between the different perspectives (value, process, coverage and type) are not in place in the lower levels. In level four, the focus on the different perspectives is tight and predominantly externally driven. In level five, there is a genuine balance between the different perspectives, with the cause-and-effect relationships being included in management on a structural basis. Also, there are safeguards to ensure that the Game Maturity Levels are linking up to the healthcare strategy and to the ecosystem of healthcare delivery as a whole.
Practice has shown that the maturity of an organization is indeed a determining factor for the way in which gamification develops. It can provide good support to managers, doctors and healthcare workers, to help them make better, more insightful decisions for achieving care objectives.
To conclude this article, we list a number of “do’s and don’ts” in implementing the Game Maturity Model:
|Implementation Game Maturity Model|
It will be clear to the reader that applying games in a healthcare context is not a one-off event. We believe that the Game Maturity Model can be genuinely used as a start and as a model for ongoing reference. We truly believe that healthcare institutions can no longer afford to see games as an activity limited to leisure time or that is something for kids. Games are dominant throughout our lives and they can often lead us to new forms of collaboration and innovation. As mentioned in the book Reality is Broken, How Games Make Us Better and How They Can Change the World, the real challenge for us today is how to integrate games more closely into our everyday lives, and how to embrace them as a platform for collaboration on our most important efforts. We as authors of this article believe that healthcare opportunities are immense, and that now is the time to take applied games seriously.
abcdeSIM (2012). “Applied games for healthcare professionals.” http://www.abcdesim.nl
Boer, J. de, A. Geert & P. Adriani, “Game Maturity Model.” Compact Magazine, 2013.
Coonradt, C. A. & L. Nelson (1985). The Game of Work: How to Enjoy Work as Much as Play. 1st ed. Deseret Book.
Defensie (2013). http://www.defensie.nl/actueel/nieuws/2013/04/12/46204671/Wereldwijde_training_via_Serious_Gaming
Hsieh, T. (2010). Delivering Happiness: A Path to Profits, Passion, and Purpose. New York: Business Plus.
KLM (2013). “The KLM Game.” http://game.klm.com/
Lee, J., D. Lee & S. Kang (2007). “An Overview of the Business Process Maturity Model (BPMM).” In Advances in Web and Network Technologies, and Information Management. Pp. 384-395. Springer Berlin Heidelberg.
McGonigal, J. (2011). Reality is Broken: Why Games Make Us Better and How They Can Change the World. New York: Penguin Press.
PWC, Global entertainment and media outlook 2013.
Reeves, B. & J. Leighton Read (2009). Total Engagement: Using Games and Virtual Worlds to Change the Way People Work and Businesses Compete. Harvard Business Press.
Team, C. P. (2002). Capability Maturity Model® Integration (CMMI SM), Version 1.1. Software Engineering Institute, Carnegie Mellon University/SEI-2002-TR-012. Pittsburgh, PA.
Wikipedia (2013). “Gamification.” http://en.wikipedia.org/wiki/Gamification