Better design for A&E

It’s safe to say that we’ve all ended up in A&E at some point, whether by skewering a finger whilst cooking, or for something more serious. While providing a crucial service, the experience can often be a less than pleasant one; there are frequently long queues of disgruntled people waiting to be seen, and often less than patiently.

Violence and aggression present serious problems for the NHS, with hospital staff experiencing more than 150 incidents per day, approximately 20% of them in A&E. The estimated cost exceeds £69m annually, though this does not account for the impact of such behaviour on staff. Turnover is high, money spent training often goes to waste, and sickness rates are costly.

Violence and aggression present serious problems for the NHS, with hospital staff experiencing more than 150 incidents per day

However, the experience of those using the emergency department at Barts Health NHS Trust, Newham University Hospital site could not be more different. The new facility is welcoming, and the usual tensions associated with people waiting for medical assistance are not discernible. So what sets Newham’s new facility apart? It is the first hospital in the UK to implement a Design Council and Department of Health initiative to reduce violence and aggression in A&E departments, and the early feedback has been very positive.

In 2011, working in partnership with the Department of Health, we ran a UK-wide open innovation competition to produce design-led improvements to A&E environments, systems and services so that the likelihood of violence and aggression occurring is reduced. A consortium led by multidisciplinary design studio PearsonLloyd was awarded £150k to develop and produce three distinct solutions predicated on behaviour change and improving the patient experience. Understanding the issue

There is a lack of official data about levels of violence specifically within A&E departments, but it is clear that abuse within A&E departments occurs frequently. Violence and aggression is particularly prevalent in A&E because they are especially complex, high-pressured and unpredictable departments. It is common to hear staff say that “no day in A&E is ever the same”. In order to understand the issue, we commissioned two ethnographic research companies to spend more than 300 hours in NHS Trusts’ A&E departments, looking at how they worked from a user’s perspective. Beyond individual characteristics that may make an individual more or less likely to be violent or aggressive, the research agencies documented a huge number of escalators of violence and aggression. These were grouped into nine separate triggers, but they are typically experienced in tandem:

1. Clash of people
2. Lack of progression/waiting times
3. Inhospitable environments
4. Dehumanising environments
5. Intense emotions in a practical space
6. Unsafe environments
7. Perceived inefficiency
8. Inconsistent response to ‘undesirable’ behaviour
9. Staff fatigue

Whilst it is widely known that some individuals, such as those with mental health problems or under the influence of alcohol or other substances are more likely to behave aggressively and violently than others, the research also suggested that nearly 50% of all incidents come from patients who are sober and that flare ups were as likely to occur from visitors accompanying the patient as the patients themselves.

A national design challenge

Insights and findings from this research alongside workshops with staff and patients led to the identification of design briefs which were issued to the UK design community through a national competition, allowing teams to propose innovative, yet practical approaches to help reduce violence and aggression in A&E departments. The winning team was a UK-based multidisciplinary consortium led by design studio PearsonLloyd, comprising some of the country’s most respected designers, researchers, evaluation consultants, senior clinicians and social scientists. They were awarded a modest R&D grant to develop practical, cost-effective solutions which could be easily retrofitted into existing NHS A&E departments. Over a four-month period we convened an independent Advisory Board, made up of senior stakeholders in health, industry and education, to support the team and offer strategic guidance. In addition, the team worked closely with the three partner NHS Trusts to research, develop and refine their concepts.

The ideal patient experience

By breaking down the different key stages of a typical patient journey through A&E, the team were able to create an ideal patient experience, which would help to inform their eventual solutions:

• The arrival experience: creating positive first impressions and managing expectations for patients and other service users
• The waiting experience: how to intervene before frustrations accumulate
• Guidance: providing information to patients and other service users to alleviate the stress of the unknown
• People: building a healthy mutual relationship between the user and the system

The team investigated each of these themes in greater detail to understand how they currently work in A&E departments. This enabled them to identify every possible opportunity for their design solutions to help reduce violence and aggression, and also helped them to understand that the solutions would have to work to certain constraints. Specifically, the solutions would need to be implementable, non-trust specific, retrofittable, flexible, and affordable.

The solutions

The team’s solutions distilled the four theme areas into three distinct outputs: Guidance, People and Toolkit.

Solution 1: Guidance

Many people become frustrated with the A&E service because of a lack of clear, effective information and guidance. This increases their anxiety and has the potential to develop into aggressive or violent episodes. The primary design output therefore focused on a guidance package that communicates essential information to the patients and other service users arriving at A&E, containing both generic information relating to the process for receiving treatment, and live information relating to the status of the department and waiting times.

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.

To accompany the ‘slices’, a process map was developed, which became the core of the communication language. This illustrated the patient journey as a series of steps moving towards the goal of treatment, with a pause (or wait) before moving onto each step. The steps were categorised into the four larger stages of check-in, assessment, treatment and outcome (or further treatment). Digital content using the same visual language, able to be updated automatically to provide more accurate and relevant information was also developed.

Solution 2: People

Over the past decade, the NHS has sought to become a more patient-centred healthcare provider. Implementing this cultural change is an ongoing process. First-time visitors to A&E still encounter a complex system – and human contact remains the best way to guide, help and reassure them. This human contact provides the interface between service users and the healthcare system, and can be considered to be the ‘customer service’ that they experience. However, the frontline staff providing this service may be subject to many systemic factors which impede their ability to deliver a patient- or service user-focused service, such as understaffing or time constraints. This may also be exacerbated by continuous negative feedback and abuse from those using the A&E service.

A two-pronged solution was proposed. The first was an induction pack for staff new to A&E, designed to help individuals joining the department understand the culture of the hospital they are entering, and the other was a system for more established staff members to promote reflection on managing problems when they arise.

Solution 3: Design toolkit

To enable any NHS Trust to implement changes to improve safety in their A&E departments, instead of redesigning just one specific waiting room or department, the designers worked on producing guidance to inspire and enable NHS Trusts to implement these changes within their A&E departments. The toolkit is a guidance document that compiles all the high level design recommendations that can help to reduce aggression and violence in A&E. These are not design solutions in themselves, but may be specifications or service changes. The toolkit breaks the patient journey down into its different stages of the A&E process and presents case studies of best practice that are in place at other NHS Trusts. It is intended to be used by all NHS staff, while also providing a reference source for architects or interior designers working on new-build projects. It will also available in greater detail as an online resource here.