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Embracing a design-led approach can improve outcomes says Haidee Bell of the Design Council, who shares the success of better A&E design which has been diffused across the health service.
A&E departments in England deal with more than 21 million patient attendances every year. These increasing patient numbers have put A&E departments under strain in the delivery of services, which can negatively affect the experiences of both patients and staff.
Patients, who are already feeling vulnerable, can become frustrated and hostilities can easily arise. Healthcare staff, many of whom are working long shifts in a high-pressure environment, often bear the brunt of these tensions. Staff well‑being in A&E departments is often very low, which can in turn affect morale.
However, for patients entering a complex system, human contact is the best way to provide guidance, help and reassurance. Improving staff morale and engagement therefore has many benefits, both for patients and for the service as a whole. Increased staff satisfaction will reduce turnover, absenteeism and their associated costs and leave staff feeling more able to offer compassion, dignity and respect.
Design Council’s A Better A&E programme demonstrated an opportunity to use a design approach to improve the patient experience, reduce hostility and aggression and provide solutions which demonstrate value for money to healthcare commissioners.
Design solutions for A Better A&E
Design Council partnered with three NHS trusts we considered broadly representative of A&E departments across the country (Chesterfield Royal Hospital NHS Foundation Trust, Guy’s and St Thomas’ NHS Foundation Trust and University Hospital Southampton NHS Foundation Trust) to research, develop and test solutions in operational A&E departments. We started by examining reports on recent aggressive incidents in UK A&E departments, and reviewed previous attempts to control and reduce this type of behaviour in public-facing services. This research was supplemented by ethnographic research, with more than 300 hours spent conducting observations and interviews in A&E departments.
We identified six ‘perpetrator characteristics’ of individuals who commit acts of aggression or violence, and nine ‘triggers’ of violence and aggression. These included the waiting experience, the effect of the environment on people’s behaviour, and how the intense emotions that play out in A&E create a ‘melting pot’ of anxiety.
A team, led by design studio PearsonLloyd, worked with specialists in organisational dynamics and clinicians to create ideas for new communication systems, staff support services and secure spaces. The design team sought to create solutions that would improve the patient experience. For patients, this meant being better informed at every stage of their journey through A&E and remaining in control of decisions.
The final recommendations provide physical changes within the A&E departments as well as creating behaviour change among patients and staff. This ‘Guidance Solution’ aims to reduce anxiety levels by using signage, leaflets and digital platforms to provide information about the department, waiting times and treatment processes.
The ‘People Solution’ supports frontline staff in their interactions with frustrated and aggressive patients. Staff are given opportunities to discuss issues and concerns, with the aim of boosting morale and reducing staff absence, and an induction booklet introduces new staff to the working culture and dynamics of the department.
Proving the impact of design
The Guidance and People Solutions were installed and initially piloted in 2012 at two A&E departments: Southampton General Hospital (University Hospital Southampton NHS Foundation Trust) and St George’s Hospital (St George’s Healthcare NHS Trust). Comparator control sites with similar characteristics were also selected for the respective pilot hospitals.
Independent evaluators, Frontier Economics and ESRO, robustly tested the impact of the design solutions by collecting primary patient and staff data through immersive methods, collecting secondary A&E data and undertaking cost-benefit analysis. Pre- and post-implementation data from the pilot hospitals were contrasted with one another, and to comparable A&E departments where the design solutions were not implemented.
The evaluation enabled us to demonstrate an impact on the patient experience, the levels of aggressive and hostile behaviour and overall value for money.
By clarifying the A&E process and improving the physical environment we were able to demonstrate an improved patient experience and reduced potential for escalation into hostility. 75 per cent of patients said that the improved signage reduced their frustration during waiting times and complaints about information and communication fell dramatically.
Both patients and staff observed significant reductions in acts of non-physical aggressive behaviour. Threatening body language and aggressive behaviour fell by 50 per cent post implementation. Associated improvements in staff morale, retention and well-being have also been reported. Installing the solutions has demonstrated considerable value for money. 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, with the greatest cost savings coming from reductions in aggressive behaviour.
In reality, these are conservative estimates of the potential benefits which could be realised from implementing the design solutions in A&E settings. Other potential benefits, such as reductions in stress-related absences, increased staff turnover and changes in litigation costs, were not included as they could not be reliably measured within the short time of the evaluation.
The adoption of the A Better A&E solutions
The evidence of the impact of the solutions has supported a campaign to see wider adoption across NHS trusts. The project has generated considerable interest: to date, 42 Trusts from across the UK and beyond have enquired about installation of the solutions. PearsonLloyd have won awards for the two solutions and are invited to speak about the project at events around the world.
However, the diffusion of innovation in the health service is slow and it took until 2015 for demand for installation to take off for the business.
For PearsonLloyd, it has been a lesson in adapting to different commissioning models across the UK health system and being responsive with their offer to reflect different processes and cultures. PearsonLloyd works with each trust to customise the solutions to the requirements of each department and also offers a template package to allow Trusts to install the Guidance Solution at a lower cost.
Kelly Pollard, from PearsonLloyd, highlighted: “I’m delighted that the solutions are now starting to show impact across sites in the UK since we know how powerful they are in improving the patient and staff experience. For us as a business it’s been a challenge to scale this service, with different commissioning processes and routes to implementation, though it has encouraged us to be responsive in the service we are offering and I’m very proud of the impact we have been able to achieve.”
Having an internal champion who really understands the approach and value offered is central to the uptake of the solutions. Hospitals are naturally risk-averse environments, therefore being able to identify someone with ability to navigate internal hospital politics and commissioning processes gives the approach credibility and helps to open doors to implementation.
To date, A Better A&E’s Guidance Solution signage has been purchased and installed by a further 10 trusts beyond the initial pilot sites.
Applying the approach beyond A&E
For Design Council, the project has informed our work within other healthcare settings. We recently worked with the Royal College of Midwives on a programme to explore ‘better births’, in which we undertook design research with patients, midwives and clinicians and identified opportunities for providing a better experience in hospital‑based maternity centres. The environment is known to impact on the process and outcomes during labour and birth and we were keen to understand what environmental factors affect patients’ confidence and sense of care.
We uncovered opportunities to look at the timeliness, tone of voice and consistency of the information presented to expectant parents throughout pregnancy and birth as well as the necessary transitions that people undertake through different environments when they give birth and how to remove avoidable anxiety. As with an A&E environment, patients enter a ‘triage’ system first, so there are some direct lessons that can be drawn about from the A Better A&E project about solutions to improve the staff and patient experience.
Design Council has also worked on two projects with the Whittington Hospital in London, one of the UK’s busiest hospitals, to look at how best to use space to improve the user experience. Over a year, Design Council Design Associates Anna White and Sean Miller worked closely with Whittington Pharmacy to analyse the service and pinpoint areas where improvements could be made.
We took a co-design approach, which meant that the designers’ focus was on allowing pharmacy users to create a space collaboratively that would work best for them. The project has measurably improved the patient experience at the Whittington, boosted staff morale and increased sales at the pharmacy.
Importantly for the hospital, it has also produced a design model that can be applied to other spaces within its walls and a willingness to experiment. The success of the pharmacy project had demonstrated that the design process could help improve the experience and efficiency of hospital services for both patients and staff, and a similar approach was later taken for its Ambulatory Care Centre, where we worked with more than 70 people across the Trust including managers, clinicians, administrators, infection prevention and control staff and patients. This gave everyone using the space a voice in the design process.
The new Centre had to be a dynamic space, allowing for a range of different departments with a wide spectrum of treatments for both children and adults. Fundamental to the design was the idea that this should be an entirely new kind of space – a chance to create a world-class unit that didn’t feel like a hospital.
The centrally located phlebotomy booth combines so much of what is successful about the new Centre. While private when necessary, it is positioned directly in the communal space demonstrating the Centre’s challenge to clinical traditions of keeping treatments, waiting and administration separate. The space very literally demonstrates the integrated care model.
The success of these projects has shown that the design process could help improve the experience and efficiency of hospital services for both patients and staff. New efficiencies and ways of working have been discovered, large financial savings made and, having used the co-design process, staff feel more involved in decision-making processes.
Design Council believes that effective, efficient and sustainable public services put the users first, and have design at their heart. These examples show that by embracing a design-led approach, outcomes can be improved, measured and scaled.
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