Finding your way through the hospital maze

My only complaint about the hospital was its design – which resembled one of those mazes that scientists use to induce stress in rats.” So says a recent visitor to one of Sussex’s more modern hospitals. He may not be alone in feeling like this. All hospitals are complex environments, and for patients, staff and visitors the ability to get from one part of the facility to another quickly, efficiently and without worry is an important one. There is no blueprint for the ideal hospital design, and that means facilities vary enormously across the UK – from the latest hospitals such as Central Manchester University Hospitals to Victorian sites such as St Mary’s in Paddington, or Whipps Cross in Epping Forest. This enormous variation highlights the need for good wayfinding design to help people enter, traverse and exit any hospital facility.

Improving the customer experience
The requirement for better wayfinding has been crystallised by the drive for improving the ‘customer experience’ across the NHS. This is a term borrowed from the commercial world, which has appreciated for many years the importance of understanding how products and services inter-relate and how this impacts on how customers feel. In the health sector it effectively encapsulates the demand for improving quality of care at all levels in all health facilities. The trend is embodied in initiatives such as the NHS Choices and the Friends and Family test, and the soon to be rolled out Care Connect website – effectively a ‘Tripadvisor’ for hospitals. Even the BBC is running a performance measure for hospitals on its news website. Everyone is watching and demanding better. People are being put at the heart of the healthcare service as never before and lessons are being learned from other industries including hospitality and aviation.
    
Let’s look at how and why wayfinding plays a vital role in making hospitals run better for everyone whether staff, patient or visitor.  There are many benefits, including financial – a recent American research study showed that the cost of an inefficient system for navigation in a major regional hospital was more than $220 000 per annum or $448 per bed.  
    
Beyond finances, there are efficiency gains which come from reducing late appointments and reducing the time taken for people to move around the facility between departments. There are emotional benefits as well with reductions in stress as people are more confident about coming into and moving around the hospital. Even for staff, who know their way around, a poor wayfinding system will have an impact as they have to spend time directing disoriented visitors as well as a more general lowering of morale. Finally wayfinding can address safety issues – ensuring that visitors don’t head to inappropriate areas, and that staff cannot become disorientated in times of high pressure, as well as reducing congestion by managing (people) traffic flows.
    
In addition good wayfinding can lead to increased patient empowerment by improving cognitive skills in spatial understanding, and increased inclusivity with signs tailored to the needs of both older and disabled patients.  There is also the question of how good wayfinding contributes to the branding of the hospital as patient and visitor friendly – the brand is significantly undermined if it cannot even deliver on a basic such as wayfinding.

More than just signage
Wayfinding starts with three key principles:  providing orientation, direction giving and decision making. There’s more to it than just signage – it is how people respond to a space or  environment, and the wayfinding strategy must help people make sense of a place and use cues to find destinations and achieve various goals. In other words, it is about people’s experience of the place and how they respond to it. Getting it right is more critical in a hospital because they are stressful environments – visitors coming to see a sick friend or relative, staff needing to provide care in a time critical fashion, or even suppliers who have busy schedules to adhere to. To develop a strategy, the wayfinding designer must understand the operational requirements of the facility, as well as understand the different types of people, their varying needs and how they will interact with the environment.

Research and audits
Research using questionnaires, observations and interviews can be used gain an understanding of peoples’ journeys, their needs, and how they interact with the architecture and spaces in the facility. The research must provide an insight into people’s full experience of the facility – from their first interaction (which may be a telephone call or letter) to the last, including the actual journey to and from the hospital. For new facilities, the research should be done as part of the master planning so that the wayfinding strategy can be integrated into the building design.
    
With existing facilities where there is an intuitive sense that the wayfinding system is not up to standard, or where refurbishment work is planned, the first step is to undertake an audit. Again, the starting point is to understand user needs, but then to measure that against the existing system.  This can be very revealing. A recent audit undertaken by CCD revealed in one hospital reception: “A jumbled mess of 15 different brown and white signs hung in an unstructured fashion from the ceiling, overlapping revealing more and more confusion the closer you got.” A large amount of signage which lacks any consistent use of colour is not untypical and often the result of signage being added over time with different strategies and sourced from different manufacturers. Temporary signage, printed by staff, stuck on the wall with blu-tac is usually a good indicator that the signage is not working.

Observation is one element of any audit, but just as important is the use of interviews to identify how the system works on a day to day basis. It is probably fair to say that as wayfinding has not been a priority for many years, if ever, there are a large number of hospitals which have become increasingly difficult to navigate as they have changed or expanded over the decades.
    
The results of an audit will provide the information needed to formulate recommendations. It is rare, if ever, that a new scheme can be implemented in one go because it can be too expensive and too disruptive in terms of operations for a hospital that has to keep working and operating. The strategy should be to create a kit of parts allowing a phased implementation, as well as enabling the scheme to grow as future changes occur and the hospital buildings change, grow and new ones are built. This ensures that a hospital can achieve short term gains at low cost, as well as preparing the ground for a more strategic approach that works to a longer term goal and takes into account future requirements.

A joined-up approach
An optimal wayfinding strategy will adopt a ‘joined up’ approach. This means knowing where any journey might start, and understanding how every stage is related. So, direction signs from local roads are important, as well as routes to the right car park and walking routes into the hospital itself.          

Naturally, not everyone comes from the same direction, or uses the same entrances but too often, signage can often be located assuming everyone comes in the main entrance.  
    
Entrances to different departments need to be clearly visible, and once inside a hospital there needs to be a balance struck between how much visitors are guided by signage, and how much they interact with reception staff. From the arrival areas, people need to be clearly guided to their destination point, and given reassurance along corridors – and if they happen to make a mistake, given the opportunity to get ‘back on track’. The strategy also needs to help people find their way out at the end of their visit – all too often this is forgotten.
    
For a hospital visitor the need for a good wayfinding strategy starts long before they arrive at the facility. For an outpatient, they need to get from home, through reception and to the right department in a timely fashion.  This might mean that their appointment letter not only tells them the time of their appointment, and the department but will also provide directions – public transport routes, which car park if they drive, which is the best entrance and how to reach the right destination point. Hospitals should regard wayfinding as just one “touchpoint” in the broader patient care experience. As it is part of the journey it has to be made to join up with all the other elements and fixing isolated parts often falls short of changing the experience.
    
Simplicity is often the key to avoiding information overload – often symbols can be used to break down barriers, and where wording is used, the preference should always be for layman’s language rather than medical terminology. Colour coding of departments can be very effective in providing immediately recognisable and easily understood destination points. This approach will also ensure inclusivity for all users.

Breaking it down
In the same way, breaking down a journey into manageable elements can be highly effective. So, for example, where someone is navigating across the hospital along numerous corridors, which probably all look the same to them, landmarks can be introduced to help people orientate and for people to be given instructions.

These need not be signs, but could be refreshment points, changes of wall colouring – anything that is describable and can be included in the directions. Hospitals’ artwork strategy can be integrated into the wayfinding, playing a functional role, as well as being aesthetically pleasing.
    
The commercial world has long understood the benefits of effective wayfinding, and the lessons that have been expensively learnt elsewhere can now more easily be applied in the health sector. Budgets are at a premium, but with the increasing need to provide a better experience for all users, hospitals need to reassess the role of wayfinding in the overall healthcare experience. The benefits are manifold, with relatively small investments providing boosts to efficiency, safety and satisfaction, as well as having a positive impact on the bottom line. Whilst the launch of NHS Choices and the Friends and Family test, doesn’t yet provide an opportunity for giving feedback on the wayfinding at any hospital, health care managers are likely to find that positive responses and satisfaction levels will improve with better wayfinding systems.

Further information
www.ccd.org.uk