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Hospital wayfinding has been the subject of much debate. In such a complex and highly stressful environment, the need for patients and visitors to find their way quickly and easily has a huge impact on the quality of their experience. As recent evidence has shown, good wayfinding is also critical in reducing potential violence and aggression, particularly in hospital A&E departments.
Two years ago, my company Whybrow Wayfinding was asked to work with design agency PearsonLloyd on a project to redesign accident and emergency departments to help reduce violence and aggression. The project was commissioned by the Design Council and the Department of Health and funded through the Design Council’s Design Challenges programme, which poses open innovation competitions to develop practical solutions to social problems. The project, [A Better A&E], helped reduce patient aggression and violence by 50 per cent.
A cost to the system
According to the National Audit Office, violence and aggression towards hospital staff costs the NHS at least £69 million a year in staff absence, loss of productivity and additional security.
The problem is particularly difficult to manage in the high-pressure environment of A&E, where pain and worry can alter the behaviour of patients and visitors, reducing their tolerance levels and making them more likely to behave aggressively.
A Better A&E developed a set of three solutions aimed at improving the patient experience by reducing tension and hostility, and preventing more serious incidents caused by accumulated aggression.
The solutions were piloted in two hospitals: Southampton General Hospital and St George’s Hospital, London, and focused on creating a calmer and more relaxing care environment through a combination of clear signage, A&E process maps and live information about waiting times.
The first of our projects, the Guidance Solution, was targeted at patients to ensure they had all the basic information about the department and how it works. Designed to be implemented in any A&E department, this solution provided a platform to communicate basic information to patients, such as where they are, what happens next, and why they’re waiting.
We coordinated the production and installation of the information touch points across the two pilot hospitals, as well as two Trusts who have since implemented the Guidance Solution.
Easily identifiable vertical information panels were applied throughout the A&E departments to explain the activities that took place in each space and how long these activities might take. They worked as standalone items, as well as a series, and were customised to each Trust. The panels were complemented by a full wall height process map illustrating the patient journey as a series of stages, from check-in to assessment, treatment and next steps so visitors can very quickly learn the process for receiving treatment.
Easy and low cost implementation was critical, and after completing a value engineering exercise we settled on direct to substrate aluminium laminate prints, which are non-porous and hygienic. The prints were mounted to walls using the ‘3M Dual Lock’ system, enabling them to be removed easily for redecoration.
Overstretched healthcare budgets require a scheme that can be retrofitted cheaply and quickly at almost any department in the country. 75 per cent of patients said the improved signage reduced their frustration during waiting times.
A supplementary leaflet in the waiting room guided patients arriving at A&E through the process, including further information about the department and contact details for other urgent care centres in the local vicinity. A tear off questionnaire provided patients and visitors with an opportunity to give feedback. 88 per cent of patients felt the Guidance Solution clarified the A&E process
A digital stream communicating live, up‑to‑date information about the department complemented the print material. Existing data stored in the computer systems automatically updated the electronic displays, providing accurate and relevant information at regular intervals.
The People Solution provided a forum for staff working in the department, supporting their interactions with frustrated or aggressive patients. For current staff, a reflective programme provided a space for staff to consider the factors that undermine their capacity to care for patients.
The goal was to identify factors that impacted the collective mood and to work to remove the root causes and to prevent them from occurring in the future.
PearsonLloyd worked with organisational psychologists Julian Lousada and Vyla Rollins to develop an eight-week programme that was conducted with eight to 10 members of staff across the department, using an external facilitator.
A new tool, the Incident Tally Chart, was developed to help focus on different variables within the system that might hinder the ability of staff to deliver high quality care. Programme findings were reported back to management, helping the department as a whole to understand, learn and improve ways of delivering care.
The programme was supplemented by an induction pack for staff new to A&E, to inform them of issues they may encounter whilst working in the department. This ensured that staff, such as trainee nurses and junior medics, had the required knowledge to work in this highly pressured environment.
The third solution took the form of an online guidance document, offering free high‑level design recommendations, focused on the built environment or service changes. The toolkit was aimed at NHS managers, clinicians and healthcare planners, who want to develop and deliver a better service in effective and inspiring environments.
The toolkit breaks the patient journey down into its different stages of the A&E process and presents case studies of best practice that are in place at other NHS Trusts. It was intended for use by all NHS staff, while also providing a reference source for architects or interior designers working on new-build projects.
Results from trials in the A&E departments of Southampton General Hospital and St George’s Hospital where the full set of solutions were piloted have been shown to improve patient behaviour.
Frontier Economics and ESRO developed a methodology that involved collection of primary patient and staff data through immersive methods, secondary A&E data collection, and cost-benefit analysis to reveal the impact of the design solutions. Improved levels of patient experience, reduced hostility and non-violent aggression, and good value for money were all noted in the evaluation.
Further installations have taken place at Newham Hospital, London and Addenbrooke’s Hospital, Cambridge, with work ongoing at Norfolk and Norwich University Hospital.
The cost benefit analysis showed that for every £1 spent on the design solutions, £3 was generated in benefits. But the value of generated benefits is expected to rise as the scheme is more widely adopted and evaluated.
Improving the visitor experience in difficult circumstances is really at the heart of this issue. We all accept that visiting A&E is usually an unplanned and anxious event for anyone, especially when our children are involved. But this anxiety can be lessened by good, clear communication at every step along the journey – a silent arm around our shoulder.
Mid Cheshire NHS Trust’s ageing IT estate was causing significant problems. Amy Freeman, the Trust’s Associate Director of IT, identified a number of challenges that needed to be addressed when she joined the organisation in 2016.