Two-pronged solution for future design of hospital A&E units

Better signage and staff training key to improving the patient experience, boosting staff morale and reducing incidents of violence

The Guidance Solution is one of two new approaches being suggested to improve the staff and patient experience of hospital accident and emergency departments

A new two-pronged approach to the design of hospital accident and emergency departments could have a major impact on the patient experience and staff wellbeing as well as save taxpayers’ money, according to new research.

The Design Council and Frontier Economics has published evidence that significant improvements could be made by implementing a new, proven design solution created by PearsonLloyd.

Based on this evidence, the Design Council recommends that trusts adopt a solution known as ‘A Better A&E’. This 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.

We are delighted that yet another collaboration between designers and the NHS has resulted in an ingenious and effective solution

The Guidance Solution promotes a series of static, fixed-format signs. Digital formats could also provide the opportunity to display dynamic and personalised information. The recognition that static, fixed information presented the best opportunity for conveying basic information to patients and other service users in A&E led to the design team developing the concept of the ‘slice’.

A narrow vertical slice in each space would be modified to contain all the information relevant to the user at that stage in the treatment process, and become the recognised communication point for patients throughout the department. This meant that rather than redesigning the whole department, or refitting each and every room, a ‘slice’ could be inserted, which would gently guide the patient or other service user along their journey through A&E.

The flexibility of this system means it can be inserted into any room, space, or corridor, creating an instantly-recognisable point for information and communication throughout the department. The ideal case scenario would be to have a four-sided slice, but when retrofitting, space constraints might mean it would have to be scaled down into one full-height panel.

A vertical slice in each treatment space would be modified to contain all the information relevant to the user at that stage in the treatment process

The slices themselves were envisaged as starting outside the building in the carpark and then continuing inside throughout the department. A handful of standard-sized wall panels were designed that could be used anywhere within A&E. A ceiling panel was also incorporated for patients arriving on stretchers. These were intended for the ambulance entrance, as well as being above the bed for resuscitation and major wards.

This evidence proves that thinking and acting differently delivers more for less in public services

In addition to the live information, the design team also identified the potential benefits of installing a touchscreen facility within A&E departments. In particular, a barcode-enabled touchscreen can enable patients to access their own records and view the waiting times particular to their own personal treatment. The touchscreens could also display information in multiple languages, and provide an audio channel for those with impaired vision.

Under the People Solution, a two-pronged system was proposed. The first was an induction pack for staff new to A&E, and the other was a system for more-established staff members to promote reflection on managing violence and aggression.

The solutions have already 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 over the last year. Key findings show:

  • 88% of patients said the new signage clarified the A&E process
  • 75% of patients said the new signage made the wait less frustrating
  • Threatening body language and aggressive behaviour has been halved
  • Offensive language and swearing has reduced by 23%
  • For every £1 spent on the design solutions, £3 was generated in benefits

‘A Better A&E’ was originally commissioned after it was discovered that 1 in 10 NHS staff members experiences violence at the hands of patients or their relatives every year. This is particularly prevalent in A&E departments and costs the service an estimated £69m per year due to high staff turnover, absenteeism and the need to employ specialist security.

The design team, led by Pearson Lloyd, was commissioned by the Design Council and Department of Health in 2011 to look at how design could create a better A&E by reducing the anxiety and frustration which often leads to violence.

‘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.

Currently, the project has been implemented at five trusts around England, including Newham University Hospital and Norfolk and Norwich University Hospital. It has also garnered interest from many others, leading PearsonLloyd to establish a stand-alone programme structure, including a dedicated website, to help implement the programme at a national level.

This solution must be adopted within A&E departments and adapted to support other healthcare settings

Mat Hunter, chief design officer at the Design Council, said: “We are delighted that yet another collaboration between designers and the NHS has resulted in an ingenious and effective solution. This evidence proves that thinking and acting differently delivers more for less in public services. This solution must be adopted within A&E departments and adapted to support other healthcare settings. We must also replicate this creative approach beyond healthcare and there is no reason why it could not be used wherever poor customer experience leads to hostility towards staff."

Tom Lloyd of PearsonLloyd added: “Rather than tackling the rare cases of physical violence against staff, the team chose to tackle the much more prevalent and often more damaging culture of low level aggression targeted at staff. Research suggested that this damaging culture of interaction between staff and patients was often stimulated simply by patients’ lack of knowledge and understanding of how the system works, and what is likely to happen to them when in that system. Thus, improving people’s experience of services helps to make them less violent or aggressive.”

The People Solution involves enhanced staff training and involvement

Frances Wiseman, divisional director of operations at University Hospital Southampton NHS Foundation Trust, said taking part in the pilot had bene a learning curve, adding: “Being involved in this project has been a catalyst for further work on staff engagement and empowerment within the trust. Certain aspects of the project have already become ingrained in the department, such as the guidance panels – it goes without saying that we will put them in our new paediatrics area.”

And Dr Sunil Dasan, emergency medicine consultant and consultant lead for quality and safety in the emergency department at St George’s Hospital, said: “We are delighted with the positive impact that the project has had on patients’ experience and on how patients perceive their time here. We are delighted to have been involved in this ground-breaking project.”

About the Design Challenge

A&E departments in England deal with more than 21 million patients every year and ever-increasing numbers have put services under severe strain.

Pressures on A&E departments can lead to negative experiences for both patients and staff. Patients, who are already feeling vulnerable, can become frustrated and hostilities can easily arise. In the complex, high-pressure environment of A&E, escalating frustrations can be particularly difficult to manage and diffuse. With A&E staff bearing the brunt of these tensions, staff wellbeing in A&E departments can be particularly low.

Recognising the significant human and financial costs of violence and aggression towards A&E staff, the Department of Health partnered with the Design Council to explore how design could be used to alleviate tensions in A&E departments.

We are delighted with the positive impact that the project has had on patients’ experience and on how patients perceive their time here

A nationwide design challenge competition invited designers to propose solutions aimed at tackling violence and aggression in A&E departments. It sought solutions to improve the patient experience, with an emphasis on understanding how processes and systems could be easily, and cost-effectively retrofitted into existing A&Es.

The winning multidisciplinary design team led by PearsonLloyd, worked with the Design Council and three partner NHS trusts to examine the typical patient journey through A&E, identifying major areas of frustration and potential triggers of violence and aggression. A set of design solutions emerged in the form of the ‘Guidance’ and ‘People projects.’ This impact evaluation has focused exclusively on these two projects.

A third output was developed as an online design toolkit, which offers recommendations to NHS trusts seeking to make improvements within their estates.

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