How rethinking design can make A&E wards safer

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. However, a new solution  by studio PearsonLloyd called ‘A Better A&E’ has been shown to result in improved patient experience, reduction in aggression and cost saving benefits.
‘A Better A&E’ was commissioned by Design Council and the Department of Health as part of their project, ‘Reducing violence and aggression in A&E: Through a better experience’, which sought design solutions to make A&E departments calmer and safer for patients and staff. The project provides a two pronged solution which incorporates a ‘Guidance Solution’ – signage to guide and reassure patients, and a ‘People Solution’ – a programme to support staff in their interactions with frustrated, aggressive and sometimes violent patients through communications training and reflective practices.

The Guidance Solution
Designed to be implemented in any A&E department, this solution provides a platform to communicate basic information to patients, such as where they are, what happens next, and why they are waiting. Information panels are implemented throughout the department so patients always know where they are within A&E and at what stage of care. These panels work as standalone items, as well as a series, and are customised to each Trust. A process map forms the core of the communication, and illustrates the patient journey as a series of stages, with a pause (or wait) between each stage. Displayed at full wall height in the waiting room, patients and visitors can very quickly learn the process for receiving treatment.
A patient leaflet supplements the signage with further information about the department and contact details for other urgent care centres in the local area. An incorporated tear off questionnaire provides patients and visitors with an opportunity to give feedback.

The print material is complemented by a digital stream that communicates live, up‑to-date information about the department. Existing data is used to automatically update the electronic displays, providing accurate and relevant information at regular intervals.

The People Solution
The second design aims to improve staff experience, recognising the key role A&E staff play in delivering a better healthcare service. For current staff, a reflective programme provides a space for staff to consider – without blame – those factors that undermine their capacity to care for patients. The goal is to identify factors that impact the collective mood and to work to remove the root causes and prevent them from occurring in the future.  

An 8-week programme is conducted by an external facilitator with 8-10 members of staff across the department.

The designers developed a new tool, in the form of an Incident Tally Chart, which is used during the programme to help focus on different variables within the system that might hinder the ability of staff to deliver high quality care. The programme findings are reported back to management, helping the department as a whole to understand, learn and improve ways of delivering care.

This is 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 ensures that staff such as trainee nurses and junior medics, have the required knowledge to work in this high pressured environment.

The solutions have been implemented at two pilot Trusts, St George’s Healthcare NHS Trust in London and University Hospital Southampton NHS Foundation Trust (UHS). The implementation has been rigorously evaluated by Frontier Economics. Findings show that the project improves A&E in three key ways.

Improved patient experience
The design solutions have improved patients’ experiences of A&E through clarification of the A&E process and improvement of the physical environment. These improvements have led to reductions in frustration and therefore a reduction in potential escalation into hostility.
Improvements in patient experience will not only reduce tensions and non-physical hostility, but prevent their potential escalation into more serious incidents, as aggression is often the consequence of accumulated frustrations. In recognition that poor patient experience is a key driver of patient frustration, patients’ perceptions of the A&E process were assessed pre- and post-implementation, with reactions to the design solutions overwhelmingly positive. 88 per cent of patients said the new signage clarified the A&E process, and 75 per cent said it made the wait less frustrating.

Reduced hostility
The design solutions set out to address non‑physical aggressive behaviour, which is a daily occurrence in A&E departments and places additional pressure on A&E staff. While severe aggressive and violent acts, such as the punching and kicking of staff are extremely detrimental when they occur, the number of reported incidents was low, in both pre- and post-implementation observations. However, it is believed that these incidents are under reported.
Since the design solutions were introduced, both patients and staff have observed significant reductions in acts of non-physical aggressive behaviour, with a 23 per cent reduction of offensive language and the incidence of threatening body language and aggressive behaviour being halved. Associated improvements in staff morale, retention and wellbeing have also been reported.

Value for money
To assess the social and economic returns associated with the design solutions, a value for money framework was used to compare the benefits of the solutions against their associated costs. The measurement of benefits focused on the reduction in non-physical aggression generated by the design solutions.

The benefits of the solutions outweighed the costs of implementation by a ratio of 3:1, meaning that for every £1 spent on the design solutions, £3 was generated in benefits. This is a conservative estimate of the potential benefits which could be realised from implementing the design solutions in A&E settings. Therefore, installing the design solutions represents considerable value for money.

Proven benefits
‘A Better A&E’ is proven to be straightforward and readily implementable and can be tailored and retrofitted to any A&E department at a relatively low cost. The impact results are a conservative estimate and a more extensive study could capture the wider benefits of these design solutions – such as operational efficiency gains – that were outside the scope of the study.
The project has been implemented at five Trusts around England, including Newham University Hospital and Norfolk and Norwich University Hospital. It has garnered interest from many others also, leading PearsonLloyd to establish a stand-alone programme structure, including a dedicated website to help implement the programme at a national level.

Further information

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