How did the project come about?
The Design Council run these things called demonstration projects, which are part of its aim to persuade the Government that design has value. This was one of those projects. We tendered for it and built quite a broad team with a psychoanalyst, an A&E consultant, some research-led people and so on.
You were looking for ways to improve Accident and Emergency wards through design. What made you focus on reducing aggression?
The focus was on physical assaults as those are the things that tend to attract the most attention. But research showed that these tend to be carried out by two or three distinct types of people – those with drug or alcohol related conditions; those with dementia-related impairments; and those with mental health conditions that lead them to confusion or anger. Those are the people who tend to be physical. But we also realised that the system and service can lead anybody to become aggressive. That aggression is typically more low level – irritability, a bit of swearing, raised voices – but in our view that’s much more corrosive to the service and more damaging to the staff, because it wears them down. For some reason A&E departments are a bit like stadiums or pubs on a Friday night, where people feel they have permission to act like that. There’s a cultural acceptance of that and we wanted to take that away.
So what specific problem did you want to address?
We came to the conclusion that if we just improved the experience of the patient, the side effect would be a reduction in anger. We didn’t want to tackle the actual aggression. We were never going to redesign the clinical pathway, because we’re not clinicians, and we weren’t going to redesign the service, because that’s too big a project and we wouldn’t be skilled enough to do that. Like keyhole surgery, we had to choose very tactical projects that we could implement. We reached the conclusion that a great deal of the problem is frustration stimulated by a lack of understanding on the part of the user. It’s classic things like someone arrives after you but gets seen before you. Nobody tells you that people are seen in order of acuity, rather than in order of arrival. A lot of the project was just explaining those types of issues and explaining the procedure patients are likely to experience.
What proposals did you make?
We started by drawing a big chart of what is likely to happen to you in an A&E. We then realised that if everybody had that in their hands, that context would give them a better trust in the service. So one of the main parts of the proposal is a big process map in the main waiting areas that is a kind of flowchart of your experience in A&E. That’s also repeated in printed leaflets and we’re reinforcing it in every space you might be in, whether it’s the X-ray room or a blood test room. Every single room, and there are about 80 in an A&E department, has a panel in it saying where you are, what the space is for, what’s likely to happen to you and why you’re there. Just really, really simple stuff. People in an A&E may be frightened and may have even been unconscious when they arrived. Having basic information is helpful.
So rather than alter the existing system, you trusted in it? When properly explained, you felt it wouldn’t generate as much confusion and aggression?
Exactly. Some of the evaluation results from this have show that people now trust the staff more because the programme lends an increased sense of trust in the system. Knowledge gives people control. The sense that you haven’t been lost in the system that is really important.
The results show a 50 per cent reduction in aggression and that 88 per cent of patients felt the proposals had clarified the A&E experience. Were you expecting such positive results?
They’re quite surprising to be honest. We talked to the evaluators and an average department has 100 staff on shift per week, each of whom will experience three verbal aggressive incidents per week. So that’s 300 per week and the reduction means 150 less of those incidents per week. Because we had a very interdisciplinary team, a lot of the clinical or social scientist types had a methodology that was more rigid than ours. As classic liberal arts designers, we take in the evidence, discuss it with people and then make a subjective judgment. I know a lot of the A&E staff didn’t think this would have the results we were hoping for.
Are results like this rewarding? Assessment of design is typically subjective, whereas these results are closer to an objective assessment of the design’s success?
So often design is a very risk-rich profession, especially when you’re trying to deliver value. Even if you’re just making a nice cushion, you’re speculating that people will like it and are taking a risk. People procuring or buying design, it’s often difficult to persuade them you can do what you say you can. Design has such a huge polarity from decorative arts to strategy or design thinking and it’s great when projects display that in an evidence-based way.
The system is currently in place in five trusts around the UK. How easy would it be to expand it to other hospitals?
One of the successes of the project is that it’s strategically easy to implement. You can put it into a cottage hospital, or a brand new super hospital. We’ve also said to people that if they want to take our research and do it themselves, they can. It’s sort of an open-source system, even if the way we’ve been implementing it is a very important part of the success. We’ve been quite consultative with each trust. One of the consultants we spoke to said that even the process of being asked what the naming strategy for each type of treatment was was helpful. It forced them to clarify the process. As professionals they’re so used to terms like “triage” that they wonder why people wouldn’t know what “triage” means. But of course none of us know what “triage” means. You only hear it from George Clooney and ER in the 1990s. Consultation is important for resolving issues like that.