Reducing violence and aggression in A&E webinar: Design solutions from Design Council on Vimeo.
Chris Howroyd
Hello and welcome. My name is Chris Howroyd, programme manager for Health at the Design Council. This is the third and final webinar hosted by the Design Council today, entitled Design Solutions. The aim of this mini-series of webinars is to share learning from this programme, engage, promote and hopefully inspire. We plan to be live for about an hour. The slideshow presentation will last for around 40 minutes, leaving us 20 minutes for Q&A.
We’ll be taking questions at specific intervals during the session so if you would like to ask, clarify or query something simply type a note into the text box on your webinar app screen.
Without further ado it’s my pleasure to introduce you to the presenter, Tom Lloyd.
Tom Lloyd
Good afternoon, this is Tom Lloyd speaking. I’m a director of PearsonLloyd, which is the lead design agency that was leading the project. We led the project with a larger team that I’ll go into in a little while.
I’d like to start with this slide, which somehow encapsulates some of the things that we’ve been trying to achieve in the project. It’s a definition of… or a root definition of the word Hospital. Two words in there, hospes and hospitium, and the word guest is particularly significant for us. The idea that you’re a guest and you’re welcomed into a place - as the root of the word Hospital - was something that we wanted to build on in tackling this project.
So I think it’s pretty clear that in some point in all our lives we may all be guests in this process, in receiving the service of hospital treatment, and particularly in an A&E department. And that may be in terms of an injury or it may be in terms of supporting someone else who’s injured and needs care.
I think this image is interesting for me because none of us know when that might happen and what state we might be in when we need that care. It might be to do with injury, illness or other reasons for being in pain and needing emergency support.
At the same time, a hospital, by definition, is a place for delivering clinical care, and I think the focus is on delivering that clinical outcome. I think some of the problems that we have identified in the project is that sometimes this sense of the clinical dominates and overrides the sense of welcoming a guess into the process.
And what tends to happen, by focusing on the clinical, our observations were that there’s often a lack of knowledge about the process when entering that system. It may be to do with language, like, what does Triage mean? It may be just to do with process: where am I, what’s likely to happen to be, who might I be talking to, what can I expect? And this sense of lack of knowledge is, again, a root to the solutions that we are proposing in the project which we think is the frustrations of which can lead to aggression and violence.
An NHS poster, a variety of which are out there, and I think it also sets up another, sort of, dynamic that exists in A&E departments which has become without intentional… with no intention it has become confrontational. Alongside putting up glass screens in reception areas there’s a sense that you’re expecting something that is unhealthy, and we believe that that expectation of confrontation is something that also leads and can lead to the thing itself.
So from being ill, injured and in pain, suddenly people become confused, frightened, and angry, and antisocial. Now, we know that within the title of the project it talks about aggression and violence, and physical assault often takes the greatest… or receives the greatest focus, especially the very violent incidents, but we believe that the low-level aggression which is much more common and heavily under-reported by staff in A&E departments is actually the root to both the solution and also the cause of the more violent incidents.
If you… the difference between a football stadium and being in a pub on a Friday night and, say, being in a library or a café, or other social spaces is that people, for some reason, in certain environments, feel they’ve been given permission to act in a particular way, and we believe that we need to change the culture, the tone, the mood in an A&E department, and by taking out the early and low-level aggression we believe that it’s possible to also reduce the permission, the, sort of, cultural permission for more violent acts to take place.
So, as a balance to the clinical, which we know is the centre of delivering the service, we want to deliver something which is more human. And they’re not mutually… they’re not mutually exclusive. They must and can work together, and we know that they can, and we know that everyone who enters care services is there to… as a service. They’re there to deliver a service and care and compassion is at the heart of… I think everyone’s ambition is to deliver good care. Sometimes, however, we believe that the focus on the clinical is sometimes at the expense of the human.
So when we were building a team to try and solve these problems, design is at the centre of that but it acts only as a, sort of, editor and as a fulcrum, if you like, for many other talents that we felt were necessary to understand and find the right solutions. So we have organisational consultants, clinicians, other specialists, who we gathered together to try and understand the, sort of, dynamic system of how people occupy a single space.
Now it’s… an A&E department is unique, we know, because everyone is in some form of pain or stress: pain, maybe, for the patients but also stress for those delivering the service. We know that, also, it’s a volatile space. It’s a volatile environment and that’s quite a unique place. So, trying to understand how people interact in that tense, volatile space was the root of the project for us. Even though the solutions may come from environmental layout and design, may come from the actual delivery of the service, or may come from information and communication, all those things have to lead to a, sort of, management of the way people communicate with each other.
And one of the great benefits of this project was that we had three NHS trusts working with us: St Thomas’ and Guy’s in London; Southampton; and Chesterfield; and along with the ethnography and the earlier research that was done with and by the Design Council we had… working closely with everyone in those departments, from consultants to nurses to receptionists to security managers, all the different skills we’ve been talking to and working with, and to get that kind of continual sense-check and reality has been a key part in delivering what we think is a successful project.
So just a few things… I’m not going to go into huge detail about the process, the design process here, but a few things that we wanted to just touch on in terms of where we’ve gathered our intelligence. Patients, the patient voice, we wanted to make sure we understood that, and one part of that was an in-depth survey we did, both online and one-to-one, and on the right of the slide there’s some interesting data around the fact that, even though the sense… the perception of clinical care is much higher than the overall perception of the service, and so there’s that… the care side of it drags down the overall perception.
And we know, actually… we all have great experiences of the NHS in terms of clinical care, and somehow the reputation is less than it should be, and that comes out of the kind of… some of the communication of the service, and we think that that, again, points us back to communicating well with the people that we’re working with.
On the back of the ethnography, which develops the perpetrator personas and those characteristics, we did our own analysis of that and tried to understand the types of people who would be coming through the system, and the types of knowledge, information, and sub-personality that would lead to violence and aggression.
And out of that we developed what we called an ideal patient experience. Again, this isn’t so much about the clinical expectation and outcome, but more about the sense of, A, being looked after, and also the sense of knowledge. And we believe that, by being more human in terms of communication, and by taking away the frustration of lack of knowledge, we believe that these are the roots to dissolving and diffusing a great deal of the issues around low-level aggression.
So, coming back to our image of the customer, of the guest, suddenly people begin to know what the service means. They begin to know what they can expect, and where they might go through the service and through the system; why are they waiting; what are we waiting for; what’s going to happen on my journey through the system, and who am I talking to?
And they seem like very, very simple things to know, but I think one of the observations, as non-clinical… we’re not… PearsonLloyd are not healthcare designers, but I think, coming in with an objective eye… I think the people working within the system feel very confident that they know, it’s obvious why this goes on and that goes on, but actually when you come in as a punter, if you like, a lack of communication was very striking to us, and talking to people and understanding why the frustrations develop, it felt like that simple sense of needing to know what’s happening, and why, and how, was a root to many of the problems that exist in the system.
Interestingly, the trigger clusters that were developed in the ethnography also began to tell us where the solution lies. So these are the trigger clusters on the slide here, and when we reflected back on our early work, back onto the ethnography, we realised that all the things we were talking about were within these phrases. So, we have the idea of lack of progression, inhospitableness, dehumanising, inefficiency and inconsistency.
But actually when you go down into those words you also find the words progression, human, hospitable, safe, efficient, and consistent. So, actually, the problems that were expressed within the ethnography were also staring us in the face as solutions. And we wanted to find… the key to this whole project is finding simple solutions, solutions that are simple in the sense that they can be understood by the user, but also simple in the sense that they can be implemented with minimal cost and into any department in the country.
It’s very important that this wasn’t dependent on new builds or large-scale projects, and with large budgets that need lots and lots of business-case developments. We wanted to find solutions that could be retrofitted with ease into the system, and that’s also a key part of the project for us.
Another reflection was the NHS constitution, which comes and goes in terms of visibility, but again the words we’re talking about in terms of care, togetherness and compassion are all there, and actually we realised that what we were trying to do is just deliver on those promises. We’re not reinventing anything, in a way, we’re just identifying some simple parts to the problem and simple elements within what we all think should be there, and trying to reinforce those things.
So, I’m going to come onto the project outputs now. We went very wide in the early phases of the project, and the image here describes the overall deliverables that we created. There were two key outputs which are there for trialling immediately, which are the Guidance project and the People project, and these are held within a design toolkit which is an online resource, which has gathered together all the benchmarking, best practice, and recommendations that we’ve gathered from all the health professionals that we’ve talked to, and all the documentation about best practice that we’ve gathered.
We hope that this, as a toolkit for people to… planning and developing new departments or refurbish departments there’s a great deal in there that will be a help, but we focused on the two projects of Guidance and People as projects that can be implemented pretty quickly at the end of the project.
But as the title says here, it’s a programme of solutions that attend to the core values of the NHS. So we’re really focusing on what’s already promised and that we can help to deliver.
So, the guidance project: what is it? It’s a communications package to create a transparent process providing basic information about the department, waiting, and treatment. And why are we doing that? By giving visitors to A&E a better understanding of how the department works and the sense that their human, as well as clinical, needs are being attended to they’re less likely to become confused, frustrated, and potentially aggressive as they progress through the system.
And how are we doing that? Retrofittable environmental graphics complemented by a live digital system, and welcoming arrival process.
So, just this slide here, in a way there’s a funny story here because as we started the project we were in our own studio office, trying to understand what it was, what an A&E department is, how you move through it and why, and what are the different spaces and processes that are there. And we realised that, actually, if everyone could have this piece of information, that would be the starting point and a, sort of, anchor to allowing people to have a sense of their own journey through the system.
So we’ve broken down the journey of receiving treatment into four stages: check-in, assessment, treatment, and outcome. And in each of those you get a sense… the map underneath is intentionally feeling a little bit like a journey map, like a tube map, so you get the sense that you have to go through a series of phases in your four or five hour… hopefully four hour or three hour process, journey. And the waiting, for example, is not a single moment. It may happen two or three times. And that there are various elements of the treatment that you will have to go through in order to deliver your… receive your clinical care.
I think it’s true to say that many people who haven’t been into an A&E department, they arrive and they see the triage pretty quickly, and then they may have to wait another two or three hours in the same waiting area but they’ve got no idea that that’s likely to happen. So from an early optimism about the service things go downhill pretty quickly in terms of perception as they wait for more elements to come along.
Other things, like the fact that someone who comes in after you may be seen before you, is a classic trigger for aggression, and many people don’t know that you’re seen in order of urgency and not attendance, for example. So this kind of information is where we wanted to start to make very clear and transparent. So this map, which would be a large-scale image in the waiting area, becomes the anchor of the communications project.
It’s a part of a wider system, and scope of information, that can go from handheld leafleting through to digital and through to environmental. We have developed various digital solutions. Some are more ambitious than others. In research terms we believe that there are opportunities for apps and touchscreens within the departments. In terms of the trialling we have decided to go for a live information screen which we’ll come to in a little while.
So, as a part of our idea and need to make something cost-effective and retrofittable, we said to ourselves, rather than redevelop the entire department, why not redevelop just a bit of the department? So we literally took a slice of each space and said, if only we could communicate clearly in every space, in every single room in a department, so that someone… any patient or friend or relative can understand what’s happening in that space and why, it would be the root to a, sort of, clearer understanding of the process.
So the idea of the slice then became a physical concept for the presentation of the communication of information. Starting even outside the space, in car parks or arrival areas outside the hospital, and then running sequentially all the way through the area… all the way through the different spaces and ward areas, right the way into a patient bay.
So the system is… has a scope of environmental graphics. They all share the same hierarchy, so that people can begin to understand, as they see them sequentially, what that means. So at the top there is an icon which describes what phase of treatment you’re in, and this is reinforced by the icons at the bottom. Again, a bit like a journey, you begin to understand where you are in the system. And the information we’re giving is terribly simple. Where I am… where am I? What stage am I at? What might be happening here? How long might I be waiting here? What are the potential times of waiting in this place? What happens at this stage or the next stage?
And this goes on all the way through the system and it’s… it serves many purposes. It’s a reassurance. If we can take away, also, the basic questions that nursing staff have to answer all the time throughout the day throughout their shifts, it also allows them to become more productive, less frustrated themselves by the… what they perceive as simple, basic questions that people should know.
The other thing we were interested in is that often you may come in semi-conscious or unconscious in an ambulance and you wake up in a bay. You maybe want to communicate with your… or ring up your friend, relative to tell them where you are and you’ve got no idea where you are. So even the sense of being able to say, look, I’m in the minors ward in bay four, and you might… to communicate that to someone, it’s also just common sense in terms of language and knowledge.
So, this is supported by a patient leaflet. Again, it explains the processes you’re likely to go through. It explains the map and some key messages about managing the expectations of the service.
We’ve tried to develop a certain amount of iconography so that it isn’t entirely language-based, but we’re also aware… the decision was made, with consultation with everyone, that we would… this shouldn’t be a multilingual approach: this should be based on the English language.
So, next to the environmental and hand-held graphics there’s a digital strategy. Within the research phase we presented four complexities of information. One is general, which is just key messages; one is live, which has a live feed of the state of business of the department; and then it goes into personal, which may be… you may be able to access your own status as a patient; and what we’re calling intelligent where… a much more interactive process between you and the hospital in terms of your treatment.
The personal and the intelligent, at the moment we’ve left to the research phase because we… if that develops it would be with further funding.
So, out of that we have, from static, large-format screens for many people to look at at the same time, then to touch-screens, and then down to personal phones and smartphones.
The live information that we’ve developed comes in… it’s primarily the live format for the shared spaces, and we’ve developed, currently, three representations of information. We’re using the data that already exists in the department when people are registered.
The first screen is about, just, the busy-ness of the department, and we want to… this is about giving people a context of why they’re waiting. Often you’re sitting in the… well, most of the time people sitting in the waiting area have no idea what’s happening in the majors ward or in the resuscitation area, and they come in and it may be relatively quiet, and then a road traffic accident, two or three patients come in as trauma patients and they draw a great deal of the staff within the department to them to save… maybe for life-saving treatment. If people understood that, people with the sprained ankles understood that that was the case, we believe that this context will give them a greater understanding of why their wait might be changing.
So, we’ve also got a waiting time screen. Now, this is a bit more controversial and will have to be tested, but we want to… this is about giving people knowledge, either about how long other people have waited within those ward areas, say, that day, or within the last couple of hours, or a prediction of what your waiting time might be into the future. And again, the sense that this will change interactively as the department gets busier or quieter.
And this is supported by the third screen, which is how many patients are in A&E, and we believe that if you know who’s in front of you within the ward areas, again you might get a sense of context about why you’re waiting.
So, just some quick illustrations of these. Again, this is very simple information, it’s quite cheap to deliver, especially the graphics are simple vinyl printouts mounted onto the walls, so we wanted to make sure that it really… it’s not dependent on, sort of, glamorous brand-new architectural fit-outs. It really can be implemented into normal spaces within existing hospitals.
Now, one of the issues that we are aware of is that, within different hospitals, there’s both language and environmental differences. So we’ve developed… at the moment we’ve developed three different colour-ways for the system. They share the same compliance in terms of DVA [?] regulations and legibility, but we’re aware that different hospitals use different colour strategies for either environmental colour or for information delivery. So here are three colour-ways. At the same time we’re also aware that different hospitals have different use of language, and the one on the screen is just a simple example, we all know very well of what the department is called but we’re also aware that different departments may or may not use the word triage, and will have different ways of describing different parts of their pathway.
So we know that, even though we’re creating a template of an information strategy, there would need to be an element of editorial control both in terms of the visual language and in terms of, actually, the content of the panels to make sure that it fits with each individual department. We don’t believe that that’s very complicated thing to do and we also think it’s important so that we can guarantee the buy-in of the staff and management so that they feel that it… they can take ownership of it.
This is just a couple of bits, images representing some of the future use of technology. So we were looking at using bar codes and… with… on armbands to allow people to access their own personal information, but this is… these are future opportunities. We also know that the use of apps is accelerating very quickly towards us.
CHRIS HOWROYD
And could you talk about the app which Bristol developed?
TOM LLOYD
Yes. I mean, there are some good examples. Currently in Bristol there’s an app where you type in your postcode and it tells you, depending on the time of day it’ll tell you what services are available to you within the appropriate distance from where you are, using GPS system, and that would include all the different services: out-of-hours GP services or other clinics and A&E departments. So we’re aware that, actually, managing the appropriate attendance to the different care delivery centres is a key part of managing and delivering the right level of care to the right people in the right place.
And we know that we… this is happening much faster than any of us have ever imagined in the last couple of years, and we believe that these tools will become useful and available and possible in the very short term.
So, the second project is the people project, and of course the first project is mainly about… is directed at the user of the service. But we know that the people who deliver the service are just as important in terms of how we support them in delivering good care, how we manage their own motivation and morale and stresses, and also how we give them the tools to handle and manage the issue of aggression and violence. This is a particular delicate project because we didn’t want to come in with another training package. We didn’t want to tell people that they must be compassionate and caring because we acknowledge that everyone is compassionate and caring in the service.
Sometimes, though, the fatigue which develops over time can begin to, sort of, wear down people’s in-built compassion, and I think we all acknowledge that the moment of aggression, many of those moments are stimulated by the wrong interaction with a staff member. And that’s not to say that there’s any fault on either side, but it is that moment of human, verbal communication which is very important.
So, what is the people programme? It’s a programme that enables staff to fulfil the core values of the NHS. It sounds very like an advert, but it is the core of where we’re coming from. Why are we doing it? To promote staff engagement, boost morale, and reduce absenteeism, as well as helping staff to develop enhanced techniques to care for different types of patient, and how.
This is a multi, sort of, pronged… a sort of circular package which includes an induction programme for new staff members and then a cyclical programme of engagement around the idea of review and noticing, and not quite reporting but zooming in on the types of aggression that take place in the department.
So we’ve developed an induction booklet for new staff. And especially in teaching hospitals the amount of people that come through for short periods of time, whether they’re trainee nurses or junior doctors is very, very high, and they often miss the training or the training doesn’t quite ever focus in on aggression and violence.
So we’ve developed a quick printed booklet that just taps in, quickly, to the different types of people, whether they’re the elderly with dementia issues, whether they’re the toxic, or whether they’re the mentally ill, or whether they are this other, sort of, majority of relatively stable people who end up becoming aggressive because of the service they’re receiving or because of the perception of the service they’re receiving.
The review part is a full… a way in which we can, sort of, acknowledge that aggression takes place. As I said earlier, aggression is the one area that is very under-reported. People kind of sigh and say, of course I’m sworn at every day but we’re immune to it. You know, it… lots of people talk about the idea that it’s almost like a war zone: you can’t… if you got stressed out about that every time it would be… you’d never get your job done. But we want to help people to… by acknowledging the low-level stuff and actually reporting it we want to use that as a way of focusing on and potentially solving those problems by developing the right skills and learning.
So the core of that is this panel, it’s this incident tally board. It’s actually a blank poster where we’ve developed a programme whereby, say, once a week over a six to eight week period we would ask a department on a shift to record a particular set of aggressions. So, for instance, in this case we’ve got male and female, and day and night. So we might just use it zooming in to see whether there are any patterns in whether different types of people may act out aggressively. And that also might be visitors or patients, it might be to do with age, it might be whether you can home in on whether it’s to do with anger or fear that’s stimulating those things.
And by… we’ve left it blank so that the people… departments can actually make their own minds up about how they might respond to their own context. It may be that the hospital is located in a city centre, which would have very different issues to, say, one on a seaside town with a large elderly population. So we tried to create a template which allows a department to focus in on the issues they are witnessing, and then we use that information as information to review and feed back and discuss the issues that are presented. And this is not intended as, sort of, robust data for management. It’s much more of an active tool for staff to use to understand their own situations.
And those groups of people - we’re not saying it’s everyone in the department, you may take a small group of people and it might be horizontal, like all the receptionists, or it might be vertical, so from consultants all the way down to domestics - and those groups would develop and develop, sort of, responses to the data that’s being collected, and we believe that, to begin with, a facilitator within the hospital would need to run these programmes. But we’ve tried to develop something that’s very light touch, that doesn’t demand a huge amount of time and energy from everyone in the department, but that’s something that can become a useful way of both acknowledging and learning, in terms of the response to violence and aggression.
Just some images. Again, simple to implement and hopefully simple to use.
And we’ve briefly been over the induction, but we’ve gathered together a lot of what we see as… and understand, and we’ve been… that… we’ve researched the best responses to different types of people, why different responses work and others don’t. And by understanding those perpetrator characteristics that we’ve developed now for the ethnography, we, sort of… we… people can become more tuned in to the issues that they are facing on a day-to-day basis.
So, out of that, those two projects are held within the toolkit, which, as I said earlier, is a overall package of guidance and guidelines and observations and recommendations that tackle issues as broad as information and education, maintenance and quality, comfort and convenience, liberty and empowerment, security and safety. So they go from, sort of, soft issues of the way people are communicated with to hard issues in terms of the, sort of, social ergonomics of laying out a department or managing daylight, or just the, sort, of, human and behaviour ergonomics of the space.
This is a very deep resource that has been developed with the Design Council online and it’ll become a… hopefully a very, very useful tool for those developing new departments.
So there’s a summary of the output. One key issue to this is in terms of implementation. It’s… much of this is simple but it also needs management, everyone, actually, to buy into this process. And so we believe that you… it’s not quite change management but it would certainly need active management and leadership to promote and empower the process to be successful, and it’s why it’s very important that the people project and the guidance project are in tandem, because we need to make sure that we support and engage with staff at the same time as communicating with the public, and those two are very much in tandem. We’re not sure that they should be separated and picked out as individual projects.
We think that the together… the working together is an important part of the success of that project, but we do also believe that a certain amount of editorial discussion will take place, and needs to take place, in order to make it appropriate for each site. We’ve so far, with the sites that… the trusts that we’ve been working with, the trials are planned to go ahead in the new year and we will be… we’re already working with them to develop their own responses to the projects. For instance, the signage may be printed locally, it may be outputted by your own estates department. So it’s not something that has to be… come in as a, sort of, external service or delivery, it can be embedded with your own… within hospitals’ own systems and structures in terms of delivering, say, a communications strategy or an HR training tool.
So at that point I’m going to stop, and I believe we’re going to go over for Q&A.
CHRIS HOWROYD
Thanks, Tom. You’ll be glad to hear we have a long list of questions. I’m going to start with one from James. His question is: violence in pubs and football matches etc tend to involve excessive use of alcohol which then leads to intoxicated patients through the doors of A&E. Is it not imperative that all A&E staff are trained in how to deal with and talk with these types of individuals to calm and more understand their manner, rather than addressing them as a burden?
TOM LLOYD
Absolutely, and we… I should have, actually, stated that in the beginning. This project does not in any way act in conflict, literally, with the security… with elements of security and conflict resolution that already exists within hospitals. For instance, the Heartlands Hospital in Birmingham, which has proved quite successful in reducing violence and aggression through particular access control and security measures, these projects can go hand-in-hand with issues around conflict resolution and managing those types of individuals as they act out their own behaviour within the department.
CHRIS HOWROYD
Right. I have a question from one of the ethnographers which we heard this afternoon, Becky Rowe: what, if anything, would you do differently on the project if you would run it again?
TOM LLOYD
I think you might have to ask me that in a couple of weeks because it’s literally completed this month. But I think… I’m not sure. I think you’ll have to ask me in a couple of weeks.
CHRIS HOWROYD
Well, perhaps I can ask a question which may be easier to answer, Tom, and that is, what do you think the biggest challenge was, and how did you overcome it?
TOM LLOYD
I think finding something which is simple and direct and understandable was particularly challenging. It’s because… because there was no direct sense of where it had come from. You know, it could have been a secure set of security measures, it could have been a new waiting area, it could have been amendments to the service plan of delivering the care. So editing down to some simple, deliverable projects was a big challenge in the project.
CHRIS HOWROYD
What other opportunities for design do you think there are as priority areas within A&E departments?
TOM LLOYD
I think there are many, many areas and I think the toolkit actually… the breadth of the toolkit, which is online, is testimony to that. Some are more attainable than others, so, for instance, getting the, sort of, spatial layout right in the hospital, in the department, can reap huge rewards, whether it’s just in terms of sightlines or making sure that your mental health suite is in the right place can reap big rewards.
I just wanted to give you the address of the toolkit, which is www.AEToolkit.org.uk and you’ll have a lot… there’s a great deal of information there that’ll help out in that.
CHRIS HOWROYD
Many accolades and congratulations, Tom, on the feed we have here. I’ll give you another question, which relates to, quite simply… I think this is from a trust: how do they implement and buy your solutions?
TOM LLOYD
Well, currently we’re working with the three trusts to trial. We’ve already had a good half a dozen other trusts who want to trial at the same time. I think the answer is to contact the Design Council because we’re hoping to pull in other trusts who want to trial in the short term, and in the slightly longer term we may develop a more formal, kind of, manual to help trusts deliver on these solutions themselves, but to begin with we’d like to manage as much of the trialling as a group as possible so that we can benefit from the, sort of, the collective learning of this experience.
CHRIS HOWROYD
All right. The next question: my question is twofold and relates to the staff project. I work in one of the four London major trauma centres and see the focus becoming more clinical and less human as the patient gets sicker and the staff become more numb to high levels of severe illness, injury, and less able to empathise with lower levels of illness and injury. Was this something that was mentioned in the design process, and were any strategies considered to deal with this?
TOM LLOYD
Actually, one of my biggest learnings, just as an individual, was that, you know, as a patient you have no idea that a nurse may have seen a child die 20 minutes before in resuscitation and then they come through and somebody else with a sprained ankle is moaning on about the fact that the vending machine has run out of Mars Bars or something. So I think that those stresses are… were… became very, very apparent. And it’s our… we were trying to… trying to communicate those realities. It’s difficult to… we know A&E departments can’t be manned for peak attendance, but it’s very difficult to communicate that with the user and so we decided that managing expectations was the best way of, kind of, dealing with that.
CHRIS HOWROYD
Right. You mentioned earlier somewhere that you’d worked with a cross-section of stakeholders within the A&E department. Was there any particular group within that cohort which were more reluctant to engage with you than others?
TOM LLOYD
Actually, no, I think we received very little… I think we were expecting, probably, slightly more resistance to the conversations. Everyone’s been willing to open up, and actually the first stage of our engagement was to really ask, what the solutions would be from their perspective. And we got a lot of information in terms of how people might solve the problems. But it was interesting that they tend to be a response to what they see and feel and receive rather than strategies to prevent the thing happening in the first place. So we had to reverse back, because we’re, obviously, trying to reduce the acts of aggression taking place in the first place, rather than saying, how do we manage security or access control in order to manage violent incidents once they’re taking place?
Obviously those strategies are still needed, but we were attempting to iron out the issues of communication and humanity to reduce levels of aggression in the first place.
CHRIS HOWROYD
Okay. Within the people project, specifically within the review element, did you design approaches or ways to facilitate behavioural change?
TOM LLOYD
Behavioural change… well, that’s an interesting one, because behavioural change comes from both the staff and from the user, and obviously the people project is targeted at the staff. But we want to… rather than telling people how to behave, in terms of staff, we wanted to use the discussion stimulated by the reporting to allow staff themselves to try and develop their own ways of amending behaviour, whether it’s their own or the users’.
I think it’s clear that, within any department, there are very experienced nurses, for example, who have great strategies for dealing with different types of aggressor; some other staff members who are notoriously bad at handling those; and other experienced staff members who’ve got no idea because they’ve only been in the service for a few months. And so we wanted to try and make that learning more explicit between those different types of people. So the ones with great experience can help share the ones with less experience, and the ones, maybe, with not-so-good ways of handling aggression and sometimes stimulate the aggression, can also begin to understand how they may change their own behaviour in response to that.
CHRIS HOWROYD
Right. Do you think those who work on the front line: clinicians, including doctors, nurses, and the medical professionals, have changed their opinion on design now with reference to what it can achieve and what value it can offer them, both physically and intangibly as far as process redesign is concerned?
TOM LLOYD
I think so, yes. I think that, unfortunately for design, it has sometimes a… there’s a, sort of, prejudice that it’s about cushions and colours, and I think, to begin with, we came across very similar responses to the idea of what design is. I think, obviously, design is a very complex and it’s a very rich, deep area of research and problem-solving. I think people were surprised by the simplicity and the directness of the solutions that have been developed, and we’ve had universal, kind of… almost universally positive response to it.
CHRIS HOWROYD
Great. And one question here, which relates specifically to colour schemes: do you think interior colour schemes play a role in the feel and redesign of spaces within hospitals, a positive role?
TOM LLOYD
Yes, I do. I think, obviously, you have to manage… for instance, one of the reasons we chose a, sort of, relatively non-clinical colour palette for the signage, for the guidance project, because we didn’t… because there are many colours that are used for information about, you know, fire, exits, or other way-finding strategies. You’ve also got, then, to use your environmental colours to, sort of, to balance all those things together. We know that different colours… you know, there’s a classic colour theory about what stimulates calmness as against anxiety, and that well-trodden colour theory is well worth taking note of when developing colour palettes.
CHRIS HOWROYD
Great. I have a question here with reference to, I think, champions of the concept. Did you explore the role of senior staff as role models to take this project forward? I know this is something which you and I have discussed on many occasions, as far as disseminating and aiding the adoption of these solutions.
TOM LLOYD
Absolutely. And we… with the trusts that we’re working with on these trials there’s an acknowledgment that we need to make sure that the right… everyone from receptionists up to senior management and back again, you need a, kind of, almost a vertical leadership plan, so that the different cohorts within the departments have an advocate for the process and a believer in the process so that it can be sustainable in the sense of working now and working in two years’ time.
CHRIS HOWROYD
Correct. Do you think, then, that you, as the design team, brought to the project anything other than a purely service-design related or orientated design agency would have brought to it?
TOM LLOYD
I think we may have come along halfway through the project and decided to go down another route in terms of a more interior-based or product-based or furniture-based response. For example, we know that the act, the moment of reception, is a key area for getting it right in terms of the way you communicate. Do you need glass screens? All those kinds of ergonomic and design issues. And potentially we made a choice at a certain point that a communications project was… had the most chance of being adopted across a wider number of hospitals. It’s difficult to design a technical, say, waiting area when actually the architectural realities of every department are different and unique.
And so we felt that the communications package would have the best chance of success across most number of sites.
CHRIS HOWROYD
Where did the mainstay of your inspiration come from for the project, the mainstay of your inspiration?
TOM LLOYD
I think it’s… I mean, we, like many designers, are not… we see that being, sort of, amateurs is an advantage, and I think Neil said this morning in the other… the first webinar: it’s very important that you have fresh eyes, somehow, and you still need to be… to use the skills of practitioners and professionals within the system, but reflect your own clarity of observation. And something we’ve been… people have been wondering this week about the simplicity of the solutions, but sometimes it’s that that, we hope, can become the most powerful thing.
Actually, strangely, the map that we created, the process map which is the, kind of, anchor of the communications package, was… as we said, was done internally in the studio for ourselves, just to try and understand what an A&E department was. And that was a bit of a, sort of, an ah-ha moment, when we realised that this could be… if everyone could access the same sense of clarity, maybe they would all have a better service.
CHRIS HOWROYD
Right. Quick question with regards to evaluation and measuring impact: are there any plans to measure the positive impact of redesign, and will the results be published?
TOM LLOYD
The answer is yes, and yes. We’ve… as a part of our commission we developed an evaluation framework. In fact, there were three evaluation streams. One was around the perception of design, to understand the impact of the project on those stakeholders working with us. The other was an expert forecast on the potential impact of the designs, which was already taking place, and the other was an evaluation framework to test and understand the impact of the solutions.
The plan is to do some baseline work on the evaluation for the implemented concepts within the next month or two, prior to the trials taking place in the first quarter of 2012.
CHRIS HOWROYD
Fantastic. Well, thank you, Tom. Just a reminder that this webinar will be available on the Design Council website. Thank you for your time, I trust you found this session interesting and thought-provoking. Thank you.