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A new approach to creating a better A&E

The Design Council and Frontier Economics recently published evidence that accident & emergency departments could improve patient experience, increase staff wellbeing and save money by using a new and proven design solution called ‘A Better A&E’. Based on this evidence, Design Council recommends that other trusts now adopt the retrofittable designs. Project manager Catherine Pratt explains.

A&E departments in England deal with more than 21 million patient attendances every year. These ever-increasing patient numbers have put A&E departments under severe strain in the delivery of services to patients.

This kind of pressure can only reap negative consequences. For instance, one in ten NHS staff experience 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 (Source: National Audit Office).

The human and financial cost is huge and the problem itself is extremely complex. Recognising that a fresh approach to the problem was required, Design Council and Department of Health commissioned a multi-disciplinary team led by design studio PearsonLloyd in 2011 to look at how design could create a better A&E by reducing anxiety and frustration, which often leads to violence.

Tom Lloyd of PearsonLloyd commented on their step-change approach to the project, saying: “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 two-pronged solution they created 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.

The Guidance Solution

Designed to be implemented in any A&E department, this solution provides a platform to communicate basic information to patients, such as where they are, what happens next, and why they are waiting.

Information panels are implemented throughout the department so patients always know where they are within A&E and at what stage of care. These panels work as standalone items, as well as a series, and are customised to each trust. A process map forms the core of the communication, and illustrates the patient journey as a series of stages, with a pause (or wait) between each stage. Because they are displayed at full wall height in the waiting room, patients and visitors can very quickly learn the process for receiving treatment.

A patient leaflet supplements the signage with further information about the department and contact details for other urgent care centres in the local area. An incorporated tear-off questionnaire provides patients and visitors with an opportunity to give feedback.

The print material is complemented by a digital stream that communicates live, up-to-date information about the department. Existing data is used to automatically update the electronic displays, providing accurate and relevant information at regular intervals.

The People Solution

The second design output aims to improve staff experience, recognising the key role A&E staff play in delivering a better healthcare service. For current staff, a reflective programme provides a space for staff to consider – without blame – those factors that undermine their capacity to care for patients. The goal is to identify factors that impact the collective mood and to work to remove the
root causes and prevent them from occurring in the future.

An eight-week programme is conducted by an external facilitator with eight to 10 members of staff across the department. They
developed a new tool, the ‘incident tally chart’, which is used during the programme to help focus on different variables within the
system that might hinder the ability of staff to deliver high quality care.

The programme findings are reported back to management, helping the department as a whole to understand, learn and improve
ways of delivering care.

This is supplemented by an induction pack for staff new to A&E, to inform them of issues they may encounter whilst working in the department. This ensures that staff such as trainee nurses and junior medics have the required knowledge to work in this high pressured environment.

The impact

The solutions have 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 by Frontier Economics.

Key findings show:

• 88% of patients said that the new signage clarified the A&E process

• 75% of patients said that 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’ 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.

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

The feedback so far has been positive. Frances Wiseman, divisional director of operations at University Hospital Southampton NHS Foundation Trust, said: “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.”

Dr Sunil Dasan, emergency medicine consultant and consultant lead for quality & safety in the emergency department at St George’s Hospital, called the initiative “groundbreaking” and added: “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.”

The bigger picture

This solution can be adopted within A&E departments, however it is easily adaptable to support other healthcare settings. This creative and design-led approach can be used wherever poor customer experience leads to hostility towards staff.

Design Council chief design officer Mat Hunter said: “This collaboration between designers and the NHS has resulted in an ingenious and effective solution. The evidence proves that thinking and acting differently delivers more for less in public services.”

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