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Service design: innovation for the employed "A better A&E in hospitals"

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Pearson Lloyd (U.K.)

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Service design: innovation for the employed "A better A&E in hospitals"

  1. 1. PearsonLloyd An award winning industrial design and innovation consultancy based in London.
  2. 2. Our Work Workplace Healthcare Aviation Public Realm Product Hospitality
  3. 3. Design: a specification of an object, manifested by some agent, intended to accomplish goals, in a particular environment, using a set of primitive components, satisfying a set of requirements, subject to some constraints.
  4. 4. What’s behind a design?
  5. 5. Design thinking
  6. 6. Design innovation
  7. 7. User engagement Stakeholders and systems Multidisciplinary teams Design-led innovation Design-led innovation
  8. 8. What? SERVICE DESIGN
  9. 9. What? Curiosity : What people need and want SERVICE DESIGN
  10. 10. What? Curiosity : What people need and want Imagine and dream up a better future SERVICE DESIGN
  11. 11. What? Curiosity : What people need and want Imagine and dream up a better future Find ways to do something about it SERVICE DESIGN
  12. 12. SERVICE DESIGN What?
  13. 13. What? You have to be there SERVICE DESIGN
  14. 14. You have to be there It happens overtime What? SERVICE DESIGN
  15. 15. You have to be there It happens overtime You don’t own it but use it What? SERVICE DESIGN
  16. 16. SERVICE DESIGN What?
  17. 17. Human empathy What? SERVICE DESIGN
  18. 18. Human empathy Holistic thinking What? SERVICE DESIGN
  19. 19. Human empathy Holistic thinking Experience prototyping What? SERVICE DESIGN
  20. 20. Service design orchestrates great customer experiences across different touchpoints to deliver value to users & providers. Purpose : Creating mutual value Value for user Valueforprovider EXPER IENCE SERVI CE PROD UCT COMM ODITY
  21. 21. Purpose : Creating mutual value - USEFUL - USABLE - DESIRABLE - EFFECTIVE - EFFICIENT - DIFFERENT Provider UserService Design
  22. 22. - Better customer experience - Reduced costs - Increased return on investment - Great new opportunities What does Service Design lead to?
  23. 23. Public Private Service Design sectors
  24. 24. Public Private Service Design sectors
  25. 25. What does Service Design look like?
  26. 26. No Red Tape: Young Taxpayers by MindLab
  27. 27. The Good Kitchen by Hatch & Bloom
  28. 28. Popup Parks (part of Knee High project) by Tom Doust
  29. 29. Improving train platform info by STBY
  30. 30. A Better A&E by PearsonLloyd
  31. 31. Department of Health NHS Specialist CarePrimary Care GPs Hospitals Urgent Care Centres UK Healthcare
  32. 32. Innovative partnership between the Department of Health and Design Council to influence the NHS to use a design-led approach to tackle problems within healthcare settings. The Organisers
  33. 33. To reduce levels of violence and aggression towards staff in Accident & Emergency departments. The Challenge
  34. 34. Problem Intangible Tangible Solution Design Process The Challenge
  35. 35. Design Process? Process
  36. 36. Exercise 1: Design process Working in groups use the cards provided to understand the design process.
  37. 37. Double Diamond process
  38. 38. Discover
  39. 39. Objectives - Identify the problem, opportunity or needs to be addressed through design. - Define the solution space. - Build a rich knowledge resource with inspiration and insights. Discover
  40. 40. Tools Discover Observing
  41. 41. Tools Discover Observing Workshops
  42. 42. Tools Discover Observing Workshops Staff interviews
  43. 43. Defining the problem Discover
  44. 44. Every year more than 55,000 physical assaults are reported by staff in NHS hospitals across the UK. Souce: NHS SMS Validated Physical Assault Statistics 2009/10 The problem Discover
  45. 45. This is particularly prevalent in A&E departments, costing the service an estimated £69 million per year. Source: A Safer Place to Work: Protecting NHS Hospital and Ambulance Staff from Violence and Aggression, published by the National Audit Office, March 2003 The problem Discover
  46. 46. In order to establish the context and project brief, the Design Council commissioned research. Findings revealed common triggers and perpetrators of violent incidents. Discover Ethnographic research
  47. 47. Perpetrator characteristics: Clinically confused/ Socially isolated FrustratedIntoxicated Anti-social/ Angry Distressed/ Frightened Discover
  48. 48. Discover Triggers of violence or aggression: - Clash of people - Lack of progression/ perceived inefficiency - Unsafe and inhospitable environments - Intense emotions - Inconsistent response - Staff fatigue
  49. 49. Understanding violence and aggression in A&E Triggers & escalators Emotional state Individual characteristics Tolerance threshold Needs & motivations Discover
  50. 50. Scale of violence and aggressionIncreasingseverity Extreme physical violence resulting in serious injury Physical violence resulting in minor injury Physical contact or damage to property Significant verbal hostility, profanity Moderate verbal hostility, inappropriate language Discover
  51. 51. An open brief issued by the Design Council and Dept of Health asked designers to reduce levels of violence and aggression in A&E. Discover The brief
  52. 52. The brief User-centred process Discover
  53. 53. The brief Versatile spaces Discover User-centred process
  54. 54. The brief A good wait Discover Versatile spaces User-centred process
  55. 55. The brief Perceptions of A&E Discover A good waitVersatile spaces User-centred process
  56. 56. The brief Making safe Discover Perceptions of A&E A good waitVersatile spaces User-centred process
  57. 57. The brief Discover Place and process clarity Making safe Perceptions of A&E A good waitVersatile spaces User-centred process
  58. 58. The response Discover Place and process clarity Making safe Perceptions of A&E A good waitVersatile spaces User-centred process
  59. 59. Discover Exercise 2: Stakeholder map Who were the stakeholders for this project? Use the worksheet to map out who you think was involved.
  60. 60. Exercise 2 : Stakeholder map Fill in the map according to the four categories of stakeholders. We will then share together. Institutions People Designers Staff
  61. 61. Institutions People Designers Staff Discover Stakeholders
  62. 62. patients doctors product service graphicNHS Dept of Health Design Council hospitals medical nurses reception security visitors family Discover Stakeholders Institutions People Designers Staff
  63. 63. Discover Observing Workshops Staff interviews
  64. 64. Discover Define
  65. 65. Objectives - Analyse the outputs of the discover phase. - Synthetise the findings into a reduced number of opportunities. - Define a clear brief for sign off by all stakeholders. Define
  66. 66. Tools Define User interviews
  67. 67. Tools Define The process: expectation Arrive TreatO utcomePatient User The system The process: reality Arrive Wait Wait Wait Wait Wait Book inA ssessM onitor TreatO utcomePatient User The system The process: userperception Wait Arrive Book inA ssessM onitor Treat Wait Wait Wait Wait OutcomePatient User The system Customer journeyUser interviews
  68. 68. Tools Define The process: expectation Arrive TreatO utcomePatient User The system The process: reality Arrive Wait Wait Wait Wait Wait Book inA ssessM onitor TreatO utcomePatient User The system The process: userperception Wait Arrive Book inA ssessM onitor Treat Wait Wait Wait Wait OutcomePatient User The system Garry, 18 Big night out, got into a up. Bleeding cuts to his head, hit his head on the kerb, potential concussion Smoker Arrives on foot, with his 3 rowdy mates. Triage: 3 Antisocial Unnecessary Distressed Frustrated Intoxicated & Socially isolated Clinically Confused Oliver, 21 Injured shoulder play- ing rugby on Wed, went to GP on Thurs, said to come back it if hurt, but came to A&E to have it checked out on Fri. Limited mobility of arm. Hurts if raises it above his shoulder. Arrives by bicy- cle, by himself. Triage: 5 Jenny, 27 Hurt her ankle when she jumped down from a wall. Suspected fracture, or sprain. Arrives in a taxi with her boyfriend. First time in A&E Triage: 4 Denise, 35, Chloe, 2 (Daniel 5, Mia 3) Chloe has a temperature, and won’t stop crying. Denise is very concerned and brings her in with her other children. Drives in. Triage: 4 Stewart, 51 Found collapsed on the street by police. Was incoherent and distressed. An alcoholic with liver damage and psychological issues. Frequent visitor to A&E Brought in by police. Triage: 3 Maria, 73 Fell down the stairs in the morning. Found by her carer late afternoon. Suspected broken hip. Has arthritis and dementia. Brought in by ambulance. Triage: 2 Customer journey Character mappingUser interviews
  69. 69. Team Design Council PearsonLloyd Helen Hamlyn Centre for Design Tavistock Consulting University of the West of England The University of Bath The Tavistock Institute Chesterfield Hospital Guy’s and St Thomas’ Hospital Southampton Hospital Psychological Project lead Organiser Design and Research NHS Partner Trusts Define
  70. 70. The design team conducted their own research to understand the user and staff perspectives. Define Research
  71. 71. The systemMe versus Patients and other service users often lack knowledge about how the A&E system works. Define A&E System
  72. 72. Define Lack of information for patients Unrealistic patient expectations Disorientation Poor waiting environment Overcrowding/lack of space Other environment Lack of privacy Noisy Drunk/Mentally ill patients Patient flow through department Poor customer service Lack of security Anxiety for themselves or others Give patients information (times/process) Staff welcoming role Better signage Encourage positive feedback Improve layout Seperate aggressive patients Decor/lighting Improve staff facilities Reduce clutter in arrival area Facilities/distractions in waiting area Access control Safe storage Education for staff Security presence in A&E CCTV Support for staff Tea trolley Lack of information for patients Unrealistic patient expectations Disorientation Poor waiting environment Overcrowding/lack of space Other environment Lack of privacy Noisy Drunk/Mentally ill patients Patient flow through department Poor customer service Lack of security Anxiety for themselves or others Give patients information (times/process) Staff welcoming role Better signage Encourage positive feedback Improve layout Separate aggressive patients Decor/lighting Improve staff facilities Reduce clutter in arrival area Facilities/distractions in waiting area Access control Safe storage Education for staff Security presence in A&E CCTV Support for staff Tea trolley Detailed research
  73. 73. ARRIVAL PEOPLE Improving staff interactions Positive first impression Making it bearable Keeping patients informed GUIDANCE WAIT Define Four themes
  74. 74. WAIT Engagement My Journey GUIDANCE Pre Arrival Guide ARRIVAL Good Relationships PEOPLE The Messages Way / What Finding A Welcome Empowerment Environment Learning and Support Define Four themes
  75. 75. Where do I park? Where’s the entrance? What’s this queue for? Should I be here? Arrival: A chain of negative experiences Define
  76. 76. Arrive Treat OutcomePatient User The system Wait: Patient expectation of process Define
  77. 77. Arrive Wait Wait Wait Wait Wait Book in Assess Monitor Treat Outcome Wait: Reality of patient process Patient User The system Define
  78. 78. Wait: Patient perception of process Wait Arrive Book in Assess Monitor Treat Wait Wait Wait Wait Outcome User The system Define Patient
  79. 79. Pre-arrival I know how busy A&E is (and if it’s a good time to go). I know what my options are (alternative services). I know how to get to hospital. I can find the A&E department easily. Arrival I’ve been greeted, acknowledged and reassured. I’ve been guided on where to go and what to do. I have a basic understanding of the service and what happens next. I know how busy A&E is (and if it’s a good time). I feel safe. I know who I am talking to. Check-in I understand the service and what happens next. I feel in the process. I feel like someone cares about what happens to me. I feel reassured and confident about what will happen to me. I feel safe. I know who I am talking to. Wait I understand the service and what happens next. I know why I am waiting. I know what I am waiting for. I know how long I’ll wait. I am free to wait in a manner that suits me. I know I haven’t been forgotten. I can find out more if I’m not sure. I’m comfortable. I feel reassured and confident about what will happen to me. I feel safe. I know who I am talking to. Assessment I understand my journey and what happens next. I know how long I’ll wait until my treatment. I feel I’m being cared for and someone cares about what happens to me. I feel safe. I know who I am talking to. Monitor/Treat I understand what’s next in my journey. I know why I’m waiting. I know what I’m waiting for. I know how long I’ll wait. I am comfortable. I know I haven’t been forgotten. I can find out more if I’m not sure. I feel reassured and confident about what will happen to me. I feel safe. I know who I am talking to. Depart I understand my diagnosis and treatment. I understand my ongoing treatment and what I do next. I know where I need to go and how to get there. I feel safe. I know who I am talking to. Guidance: Ideal patient experience Define
  80. 80. Guidance: The patient journey We need to have a positive interaction at each stage of the journey And we need to stay in touch throughout the visit to A&E Pre-arrival Arrival Wait Treatment Outcome Define
  81. 81. PHYSICAL High level VERBAL Low level AGGRESSION FRUSTRATION VIOLENCE Prevention Intervention Define Guidance: Prevention vs. Intervention
  82. 82. Guidance: Type of support Where’s the water fountain? Please queue to register here Treatment in order of priority Where’s A&E? What finding Information Instruction Wayfinding Define
  83. 83. Define Communication Service Environment People: Integrated service Working with staff to deliver a better service
  84. 84. People: Type of support What are the protocols? How to report incidents Warning signs of perpetrators What measures are in place? Induction Information Instruction Support Define
  85. 85. Define Exercise 3: Character mapping Using the worksheet, try to understand what the characteristics and mindset of a potential perpetrator might be.
  86. 86. Exercise 3 : Persona Create a character to get into the mindset of a potential perpetrator to understand his/her behaviours and needs in A&E. Clinically confused/ Socially isolated FrustratedIntoxicated Anti-social/ Angry Distressed/ Frightened Type of perpetrator : Gender: Name: Age: Life situation (level of life, job, children, married...): Cause of injury: Type of injury or treatment: Add other info (i.e. first time in A&E, frequent visitor, pre-existing condition...): How did (s)he get to the A&E:
  87. 87. Garry, 18 Big night out, got into a fight. Drunk and coked up. Bleeding cuts to his head, hit his head on the kerb, potential concussion Smoker Arrives on foot, with his 3 rowdy mates. Triage: 3 Antisocial Unnecessary Distressed Frustrated Intoxicated & Socially isolated Clinically Confused Oliver, 21 Injured shoulder play- ing rugby on Wed, went to GP on Thurs, said to come back it if hurt, but came to A&E to have it checked out on Fri. Limited mobility of arm. Hurts if raises it above his shoulder. Arrives by bicycle, by himself. Triage: 5 Jenny, 27 Hurt her ankle when she jumped down from a wall. Suspected fracture, or sprain. Arrives in a taxi with her boyfriend. First time in A&E Triage: 4 Denise, 35, Chloe, 2 (Daniel 5, Mia 3) Chloe has a temperature, and won’t stop crying. Denise is very concerned and brings her in with her other children. Drives in. Triage: 4 Stewart, 51 Found collapsed on the street by police. Was incoherent and distressed. An alcoholic with liver damage and psychological issues. Frequent visitor to A&E Brought in by police. Triage: 3 Maria, 73 Fell down the stairs in the morning. Found by her carer late afternoon. Suspected broken hip. Has arthritis and dementia. Brought in by ambulance. Triage: 2 Define Character mapping
  88. 88. Discover Define User Interviews Customer journey walk through Character Mapping
  89. 89. Discover DevelopDefine
  90. 90. - Develop the initial brief into a product or service for implementation. - Design service components in detail and as part of a holistic experience. - Iteratively test concepts with end users. Objectives Develop
  91. 91. Tools Prototyping Develop
  92. 92. Tools Prototyping Visualising Develop
  93. 93. Tools Prototyping User testingVisualising Develop
  94. 94. Design essentials It was crucial for the solutions to be: – Easily implementable – Non-Trust specific – Retrofittable – Flexible – Affordable – Effective Develop
  95. 95. Develop
  96. 96. Develop
  97. 97. Exercise 4: Patient journey Develop Using the worksheet provided to map a patient’s journey through A&E.
  98. 98. Exercise 4 : Patient journey Map the stages of the patient’s journey. What is the step by step experience of the patient? It will help you to understand how the designers used the research to develop designs. Develop
  99. 99. Develop Patient Journey
  100. 100. Develop
  101. 101. Develop
  102. 102. Develop
  103. 103. Develop Department overview
  104. 104. Entrance Meet & Greet Waiting room: Process MapReception Develop Visualising
  105. 105. 17/08/2011 © PearsonLloyd| A&E project, outputs presentation WORK IN PROGRESS 7 A&E Carpark Waiting room Reception Ambulance Walk-In Tests Results Resus Admittance See & Treat Discharge DischargeWait Minors Handover WaitMajors CDU TriageArrival Check-in Wait 1. Check in 2. Assess 3. Treatment 4. Result Outside ReceptionGreeter /Ticket Process Supergraphic Major Discovery Point 1000 500 2000 1500 2500 600 420 3600 (4200) 3600 600 1200 3000 live info kiosk wait Reception 1 Reception 2 2324 Enquiries T o d a y W a i t i n g r o o m W a i t i n g r o o m M a j o r s M a j o r s Minor Discovery Point Bay Discovery Point Mobile Info 420 420200 200 ticketsboard white board poster posterboard 1000 500 2000 1500 2500 600 1200 Scope This shows the full scope of the proposed intervention, giving an overview of how the visual language feeds through to the different spaces. Outside Minors Information Point Greeter/Ticket Bay Information Point Reception Mobile Info Process Map Staff Areas Majors Information Point 17/08/2011 © PearsonLloyd| A&E project, outputs presentation WORK IN PROGRESS 7 A&E Carpark Waiting room Reception Ambulance Walk-In Tests Results Resus Admittance See & Treat Discharge DischargeWait Minors Handover WaitMajors CDU TriageArrival Check-in Wait 1. Check in 2. Assess 3. Treatment 4. Result Outside ReceptionGreeter /Ticket Process Supergraphic Major Discovery Point 1000 500 2000 1500 2500 600 420 3600 (4200) 3600 600 1200 3000 live info kiosk wait Reception 1 Reception 2 2324 Enquiries T o d a y W a i t i n g r o o m W a i t i n g r o o m M a j o r s M a j o r s Minor Discovery Point Bay Discovery Point Mobile Info 420 420200 200 ticketsboard white board poster posterboard 1000 500 2000 1500 2500 600 1200 Scope This shows the full scope of the proposed intervention, giving an overview of how the visual language feeds through to the different spaces. Develop Scope
  106. 106. 0845 4647 0000 Your comments (continued) Please tell us what went well, and what we could improve. Please tear off this page and put it in the‘Comments’box. You can also post your comments to: Patient services, Anytown Hospital, Walking way, Big City DR12 0FU Or email: feedback@ght.nhs.org.uk ALL ABOUT A&E AnyTown Hospital, Address line 1, Address line 2 000 1111 2222 Our staff Many people with different skills work in the Emergency Department. Here are some of them: Receptionists book you in for assessment and treatment. You can ask them about what to expect in the Emergency Department [or other question(s)]. Nurses assess your illness or injury. They may then treat it or if necessary, ask a doctor to see you as well. Doctors work with nurses in your treatment. They may advise that you need further tests or a particular kind of treatment. Radiographers take x-rays, which show whether you have broken a bone, for example. Follow-up treatment After being treated in the Emergency Department you may need further treatment, either at this hospital, with your GP or at home. Our staff will advise you about any follow-up treatment that you may need. If you are unsure about anything, please ask. When you get home, we hope that you will stay well. But here are some useful contacts for any health problems or worries: If you need to see your local GP outside normal working hours, you can contact them on: [020 7587 45315] There is an NHS walk-in centre at: Address: Opening hours: Telephone: About us The Emergency Department is for people who need immediate medical diagnosis and may need emergency treatment. Our top priority is treating people with urgent or life-threatening illnesses and injuries. If your illness or injury is less urgent, you may get advice and treatment more quickly at your local GP, walk in centre or urgent care centre. Unwell? Unsure? Need help? For any questions about health and confidential advice, contact NHS Direct 1. Check in 2. Assess 3. Monitor Your comments Welcome to the Emergency Department. Please take a ticket. This is your place in the queue. If you are visiting someone, you still need a ticket, so that you can be escorted to the patient. PLEASE KEEP HOLD OF YOUR TICKET. If you are accompanying a child, please go to the‘Children and parents’ seating area. When your number is called please go to the‘Welcome’desk to check-in. When you hear your name called one of our nurses will see you to assess your illness or injury. Your treatment will depend on how serious your illness or injury is. We treat the most serious illnesses and injuries first, so some patients may need to wait longer than others. If you are worried about waiting, please talk to the nurse who sees you. We will treat you as soon as possible, but waiting times can be long when the department is very busy. We’ll aim to see you within four hours. We are always keen to improve the Emergency Department service. If you have a few spare moments, your comments are helpful. 1. I am satisfied with the service I received at the Emergency Department 2. I did not have to wait longer than I expected. 3. The staff were helpful. 4. The staff explained my treatment clearly. We may have to do additional tests before we can fully diagnose and treat you. This may take some time. The tests could include: • X-ray, to check for broken bones or other problems that may not be visible on the surface. • Urine sample, to check for conditions such as [EXAMPLES] • Blood tests, which can show if you have [EXAMPLES] If you are worried about anything or have any questions, please feel free to ask our staff. Agree1 2 3 4 5Disagree Agree1 2 3 4 5Disagree Agree1 2 3 4 5Disagree Agree1 2 3 4 5Disagree 4. Treat When we have assessed your illness or injury, we will ask you to come through to the ward, where you can have any further tests done and be treated. There are three main ward areas where you may be treated: minors, majors and resus. If you are worried about anything or have any questions, please feel free to ask our staff. Develop Patient Leaflet
  107. 107. Reflection Learning Reporting RECOVERY Staff solution Develop
  108. 108. RESPECT AND DIGNITY Valuing each person as an individual, understanding their priorities, needs, abilities and limits. COMMITMENT TO QUALITY OF CARE Getting the basics right everytime. We welcome feedback, learn from our mistakes and build on our successes. COMPASSION Responding with humanity and kindness to each person’s pain, distress, anxiety or need. IMPROVING LIVES We strive to improve health and well- being and people’s experiences of the NHS. Working in A&E is a unique experience, which will constantly challenge you to be at your best, under the most difficult circumstances. In the next few pages, you’ll find an overview of the values we believe in and ask you to uphold these whilst you are here. We aim to create the best experience possible for our patients and their relatives and ask you to consider how this might be achieved. We can each contribute towards this goal. This guide is to help you understand what we expect from you. In return, we aim to support you in your work and help create a happy vibrant workplace. Susan, Head Matron A&E, St Fiction Hospital People’s attitudes and behaviours are closely interlinked. And these will affect the attitudes and behaviours of those around them. Patient and their relatives that arrive at A&E may be in severe pain or distress, and this may cause them to behave in a way they wouldn’t normally. It is very easy for this to trigger off a negative cycle, with each interaction contributing towards a downwards spiral. The skill lies in turning this around into a positive cycle of mutual respect. Remember that you have a choice in how to respond. Your positive attitude and behaviour can help to influence others. LEAPS is a communication technique that can help you defuse and resolve a potentially difficult situation. L : Listen Listen twice as much as you talk; that’s why you have 2 ears and 1 mouth! What is the difference between listening and hearing? Listen for the total meaning and focus on what the patient is telling you E : Empathise The point of empathy is to put ourselves emotionally, in the other person’s position. Paraphrasing what they’ve said shows that you are trying to understand their message. This helps to develop a mutual trust and respect for each other, and creates a platform for further dialogue. A : Ask This is where we can ask questions to clarify anything that’s ambiguous, and confirm our understanding of the situation. P : Propose Only after we’ve listened, empathised and asked, are we in a position to propose a solution. The goal is to find a resolution and return to a calm state. Whilst we may not be able to treat them more quickly, offering a glass of water or cup of tea, may help them to feel cared for. If used effectively, this process can help prevent communication breakdowns before they escalate. Whilst working in this department, you may find some events distressing. This is a good and human reponse. Whilst it can be tempting to brush these things off, discussing it with someone can help to resolve your emotions. Our Chaplain is on hand to talk, whenever you want to. You can contact him on: 0207 456 7861. ‘Working in A&E was an incredibly challenging experience in development as a nurse, but I found it also to be incredibly rewarding. Helping people at their most vulnerable, through life and death, makes you really realise what the important things in life are.‘ My Attitude My Behaviour Your Behaviour Your Attitude Pete, trainee nurse Care goes beyond clinicalWelcome to our A&E team! We are all connected It’s good to talk A helping hand WORKING TOGETHER FOR PATIENTS We put patients first in everything we do, by reaching out to staff, patients, carers, families, communities, and professionals outside the NHS. EVERYONE COUNTS For the benefit of the whole community, excluding nobody, and accepting that some people need more help. We aim to maintain these values throughout a patients journey through A&E. A difficult task at times, but one well worth doing. All about A&E Socially isolated Individuals who may be without a diagnosable medical problem and consider A&E a place of safety and a way to receive attention. Often regular attenders at A&E, these individuals may look unkempt, unstable, or have poor personal hygiene. While often harmless, these individuals can be manipulative or threatening at times. Their knowledge of the system can be used to get around basic security measures. Personal knowledge of staff that has been built up over time can make their behaviour more distressing and vivid. Sometimes these characters are good at utilising other patients to act on their behalf. Distressed/ frightened Individuals who are undergoing an intense emotional experience which preoccupies their thoughts and may lead them to behave in an irrational or erratic manner. Such people often appear frantic or agitated; they may be physically shaking, flushed, or visibly panicked. As emotions run high, individuals may be pre- occupied, struggle to listen and be difficult to reason with. Individuals may be unusually volatile and unpredictable. Antisocial/angry Individuals with a tendency owards violent aggressive behaviour and a far lower threshold for responding to triggers. There are no easy ways to detect ‘anti- social’ people.They may take an aggressive stance, swear excessively, or speak in a loud voice. They are likely to be ‘antisocial’ in a variety of contexts and may also act in a negative or abusive way in the absence of triggers. It is more likely that these individuals have little respect for any kind of authority or rules, and may be unafraid of the consequences of behaving badly. Intoxicated Individuals who are drunk or otherwise intoxicated and may have diminished self- control or perception of the consequences of their actions. Drinking alcohol and taking some drugs can reduce people’s social anxieties and make the drinker less likely to worry about the consequences of his or her actions. The effects of alcohol on cognitive functioning may reduce the individual’s ability to process or remember even basic instructions or solve simple problems. Frustrated Individuals who are considered ‘reasonable’ when first presenting at A&E, but who are driven past their tolerance threshold by the triggers and escalators they experience while in the A&E environment. Some may make their frustration clear long before they would resort to violence or aggression; others may simply ‘erupt’ with seemingly no advance warning at all. Indeed, it may also take the individual by surprise – a momentary loss of control or impaired judgement. Clinically confused Individuals who have a medical condition or illness which can result in violent or aggressive behaviour that is believed to lack intent. More often found in ‘majors’.These individuals may either be in an unresponsive state or behaving oddly. For whatever reason, these individuals may not be in control of their behaviour or their reaction to stimulus. Our Patients Violence and aggression in A&E is typically thought of as being related to alcohol or drugs.The reality is far more complex and people can act out for a variety of reasons. The different types of patient types are shown over the next few pages. Understanding the reasons for people’s behaviour enables us to respond in the most appropriate way and de-escalate situations more quickly. By familiarising ourselves with these patient types, we can pick up on warning signs earlier, tailor our responses accordingly, and help prevent confrontations from occurring. There may be more patient types, so a page has been left blank for a new type. Develop Staff Perspective
  109. 109. FRUSTRATED Individualswho areconsidered ‘reasonable’ whenfirstpresentingat A&E,butwhoare drivenpasttheir tolerancethresholdbythe triggersandescalatorsthey experiencewhileintheA&E environment.Somemaymaketheirfrustration clearlongbeforetheywouldresort toviolenceoraggression;others maysimply‘erupt’withseemingly noadvancewarningatall.Indeed,it mayalsotaketheindividualby surprise–amomentarylossof controlorimpairedjudgement. INTOXICATED Individualswho aredrunkor otherwise intoxicatedand m ayhave dim inished self-controlor perceptionofthe consequencesof theiractions. Drinkingalcohol andtakingsom edrugscan reducepeople’ssocialanxietiesand m akethedrinkerlesslikelytoworry abouttheconsequencesofhisor heractions. Theeffectsofalcoholoncognitive functioningm ayreducethe individual’sabilitytoprocessor rem em berevenbasicinstructions orsolvesim pleproblem s. Individuals who have a medical condition or illness which can result in violent or aggressive behaviour that is believed to lack intent. More often found in ‘majors’. These individuals may either be in an unresponsive state or behaving oddly. For whatever reason, these individuals may not be in control of their behaviour or their reaction to stimulus. CLINICALLY CONFUSED Individuals who may be without a diagnosable medical problem and consider A&E a place of safety and a way to receive attention. Often regular attenders at A&E, these individuals may look unkempt, unstable, or have poor personal hygiene. While often harmless, these individuals can be manipulative or threatening at times. Their knowledge of the system can be used to get around basic security measures. Personal knowledge of staff that has been built up over time can make their behaviour more distressing and vivid. SOCIALLY ISOLATED Individuals whoare undergoing anintense emotionalexperience whichpreoccupies theirthoughts and maylead them tobehave in anirrational orerratic manner.Such people oftenappear frantic oragitated; they may be physically shaking, flushed, or in a visibly panicked state. As emotions run high, individuals may be pre-occupied, struggle to listen and be difficult to reason with. Individuals may be unusually volatile and unpredictable. DISTRESSED /FRIGHTENED Individuals with a tendency owards violent aggressive behaviour and a far lower threshold for responding to triggers.There are no easy ways to detect ‘anti-social’ people. They may take an aggressive stance, swear excessively, or speak in a loud voice. They are likely to be ‘antisocial’ in a variety of contexts and may also act in a negative or abusive way in the absence of triggers. It is more likely that these individuals have little respect for any kind of authority or rules, and may be unafraid of the consequences of behaving badly. ANTISOCIAL / ANGRY FRUSTRATED Individualswho areconsidered ‘reasonable’ whenfirstpresentingat A&E,butwhoare drivenpasttheir tolerancethresholdbythe triggersand escalatorsthey experiencewhileintheA&E environment.Somemaymaketheirfrustration clearlongbeforetheywouldresort toviolenceoraggression;others maysimply‘erupt’withseemingly noadvancewarningatall.Indeed,it mayalsotaketheindividualby surprise–amomentarylossof controlorimpairedjudgement. INTOXICATED Individualswho aredrunkor otherwise intoxicated and m ayhave dim inished self-controlor perception ofthe consequencesof theiractions. Drinking alcohol and taking som edrugscan reducepeople’ssocialanxietiesand m akethedrinkerlesslikelyto worry abouttheconsequencesofhisor heractions. Theeffectsofalcoholon cognitive functioning m ayreducethe individual’sabilityto processor rem em bereven basicinstructions orsolvesim pleproblem s. Individuals who have a medical condition or illness which can result in violent or aggressive behaviour that is believed to lack intent. More often found in ‘majors’. These individuals may either be in an unresponsive state or behaving oddly. For whatever reason, these individuals may not be in control of their behaviour or their reaction to stimulus. CLINICALLY CONFUSED Individuals who may be without a diagnosable medical problem and consider A&E a place of safety and a way to receive attention. Often regular attenders at A&E, these individuals may look unkempt, unstable, or have poor personal hygiene. While often harmless, these individuals can be manipulative or threatening at times. Their knowledge of the system can be used to get around basic security measures. Personal knowledge of staff that has been built up over time can make their behaviour more distressing and vivid. SOCIALLY ISOLATED Individuals whoare undergoing anintense emotionalexperience whichpreoccupies theirthoughts and maylead them tobehave in anirrational orerratic manner.Such people oftenappear frantic oragitated; they may be physically shaking, flushed, or in a visibly panicked state. As emotions run high, individuals may be pre-occupied, struggle to listen and be difficult to reason with. Individuals may be unusually volatile and unpredictable. DISTRESSED /FRIGHTENED Individuals with a tendency owards violent aggressive behaviour and a far lower threshold for responding to triggers.There are no easy ways to detect ‘anti-social’ people. They may take an aggressive stance, swear excessively, or speak in a loud voice. They are likely to be ‘antisocial’ in a variety of contexts and may also act in a negative or abusive way in the absence of triggers. It is more likely that these individuals have little respect for any kind of authority or rules, and may be unafraid of the consequences of behaving badly. ANTISOCIAL / ANGRY incident reports A&E Culture Intro A&E Structure Home Patient types RESPONSE Individuals who may be without a diagnosable medical problem and consider A&E a place of safety and a way to receive attention. Often regular attenders at A&E, these individuals may look unkempt, unstable, or have poor personal hygiene. While often harmless, these individuals can be manipulative or threatening at times. Their knowledge of the system can be used to get around basic security measures. Personal knowledge of staff that has been built up over time can make their behaviour more distressing and vivid. SOCIALLY ISOLATED “Why are you letting that woman in before me!?” Tone of voice: Assertive, reasoning Response: Body language: INTOXICATED Individuals who are drunk or otherwise intoxicated and may have diminished self-control or perception of the consequences of their actions. Drinking alcohol and taking some drugs can reduce people’s social anxieties and make the drinker less likely to worry about the consequences of his or her actions . The effects of alcohol on cognitive functioning may reduce the individual’s ability to process or remember even basic instructions or solve simple problems. RESPONSE “ Get your filthy hands off me. My leg hurts and I’m trying to sleep.” Develop Staff Perspective
  110. 110. 254 Changes in activity and posture • Increased or prolonged restlessness, body tension, pacing and excitability. • Irritability. • Extreme anxiety. Invasion of personal space • Intrusive demands for attention. • Blocking escape routes. • ‘Eye balling’. You should take immediate precaution when any of these signs are identified. The context Why do visitors become violent or aggressive? Personality Pain/Anxiety Quality of service Environmental factors Violence/Aggression Firstly, there is the individual or potential perpetrator. This person may possess a number of pre-existing characteristics that may make them more likely to commit a violent or aggressive act: for example, heightened stress levels, a tendency to violence, under the influence of drugs or alcohol, impaired reasoning or a short temper. STAFF BOOKLET PAGINATION CMYK 141111.indd 7-8 14/11/2011 18:03:15 524 Warning signs There are several cues that warn of imminent aggression and can help you to be aware of the visitor’s state of mind: Verbal aggression and threats • Facial expressions tense and angry. • Increased volume of speech. • Prolonged eye contact. • Discontentment, refusal to communicate, withdrawal, fear, irritation. • Verbal threats or gestures. • Reporting anger or violent feelings. It is also widely accepted that pain and discomfort increase aggression (e.g. Berkowitz, 1988), which means a patient’s symptoms can increase their likelihood of acting aggressively or violently. Secondly, there are also escalators or triggers of violence and aggression. These are factors that are external to the individual, and could be associated with comfort, service experience or the presence of other people. In any given context, the combination of personal characteristics and experiences, plus the presence of triggers or escalators, creates a ‘breaking point’ at which an individual will diverge from their normal pattern of behaviour. STAFF BOOKLET PAGINATION CMYK 141111.indd 9-10 14/11/2011 18:03:15 Develop Staff Handbook
  111. 111. INCIDENT DIARY INTOXICATED CLINICALLY CONFUSED SOCIALLY ISOLATED DISTRESSED FRUSTRATED ANTISOCIAL Mark each time a patient/visitor is aggressive or violent: DATE: SOCIAL Develop Reporting
  112. 112. Incidents Reporting The incident reporting system is a good way to Oreri dolupta sunt et quatur, consenem es imenis non paris nus. Isin parciatia cum harumque vel enienis aciatem hilibus expeles tiatur sim dis eturis estiusantiam re preicipic te debisque porrum etur assitatur? Ulpa nem. Nam ratet officimi, tem is aute Odis ducition reritibusant odit magnis voluptur, quam estis eaquidesedi tem quia que volent periorp orporpore vollest, vernatur, sum que exerci ommos arit faci ut. This week Championed by: Staff participating: Variables: Results: Develop Reporting
  113. 113. Prototyping Discover DevelopDefine User testingVisualising
  114. 114. Discover DevelopDefine Deliver
  115. 115. Objectives - Taking product or service to launch. - Ensure customer feedback mechanisms are in place. - Share lessons from development process back into the organisation. Deliver
  116. 116. Tools Deliver Implementation
  117. 117. Tools 88% 82% 78% 75% Patients’ perceptions of the Guidance Solution Impact of design solutions on hostility and non-physical aggression -50% -25% -23% -2% Evaluating Deliver Implementation
  118. 118. Tools 88% 82% 78% 75% Patients’ perceptions of the Guidance Solution Impact of design solutions on hostility and non-physical aggression -50% -25% -23% -2% Distributing conclusionsEvaluating Deliver Implementation
  119. 119. The team created a three-pronged set of design solutions tailored to the different needs of patients and staff. Deliver The solutions
  120. 120. PEOPLE INFORMATION IMPLEMENTATIONImproving staff interactions Keeping patients informed GUIDANCE Deliver TOOLKIT Free design recommendations The solutions
  121. 121. An information package that guides patients through A&E, ensuring they have information about the department and how it works. Deliver Guidance Solution
  122. 122. Deliver
  123. 123. OutcomeTreatmentAssessmentCheck in Deliver
  124. 124. OutcomeTreatmentAssessmentCheck in Your journey through A&E Walk in Ambulance The receptionist will check you in. For people with life-threatening injuries or illnesses. For people whose injuries can be assessed and treated in one step. A nurse will assess the urgency of your injury or illness. Most people will be able to leave A&E after treatment. For people with very urgent injuries or illnesses. We may need to find out more about your injury or illness. People who need further treatment will be admitted to a hospital ward. For people with less urgent injuries or illnesses. You will be treated in order of urgency. You will be seen by a nurse in order of arrival. You may have to wait while we process your test results and decide on the best treatment. Tests Handover Check in Hospital Assessment Leave A&E Major Injuries See & Treat Minor Injuries Resuscitation Deliver
  125. 125. 1 - Where am I? 2 - What’s the most important thing I need to know? 3 - Why am I waiting? How long will I wait? 4 - What happens at this stage? 5 - Where am I in the process? Check in Please take a ticket. Reception staff will call you and ask for details like your name, address, date of birth and next of kin. At busy times there may be a short wait before your ticket number is called. People who are very unwell may be taken to a treatment room immediately. In this case, a receptionist will be called to the treatment area to complete their registration. Check-in Assessment Treatment Outcome Deliver
  126. 126. Walk in Ambulance The receptionist will check you in. For people whose injuries can be assessed and treated in one step. A nurse will assess the urgency of your injury or illness. Most people will be able to leave A&E after treatment. For people with very urgent injuries or illnesses. We may need to find out more about your injury or illness. People who need further treatment will be admitted to a hospital ward. For people with less urgent injuries or illnesses. You will be treated in order of urgency. You will be seen by a nurse in order of arrival. You may have to wait while we process your test results and decide on the best treatment. Tests Handover Check in Hospital Assessment Leave A&E Major Injuries See & Treat Minor Injuries People in this area may be at different stages of assessment or treatment. A&E Waiting area This A&E Department is often very busy. We aim to treat everyone as quickly as possible, but waiting times can be long. Thank you for waiting patiently. We see the most urgent cases first. This means that people who arrived after you may be called first. Check in Please take a ticket. Reception staff will call you and ask for details like your name, address, date of birth and next of kin. People who are very unwell may be taken to a treatment room immediately. At busy times there may be a short wait before your ticket number is called. When the nurse has assessed your injury or illness, we will have a good idea of how serious it is and what type of treatment you may need. We aim to treat the most urgent injuries and illnesses first. We aim to assess you within 30 minutes after check-in. Please wait for your name to be called. A nurse will assess the urgency of your injury or illness and talk to you about the type of treatment you need. Assessment Within each priority category, we treat the most serious cases first. Patients who arrive by ambulance are assessed in the same way as people who arrive unassisted. A specialist nurse, called the triage nurse, will assess the urgency of your injury or illness. Assessment Categories Priority 1 Priority 2 Priority 4 Priority 5 Priority 3 Everyone is assessed using the same scale of priority categories: from 1 (life-threatening) to 5 (non-urgent) Please wait for your name to be called by one of our technicians. Children will be seen first, whenever possible. During busy periods you may have to wait. This unit takes x-rays for A&E and other departments in the hospital. X-Ray Seating area The Major Injuries area is for people who have a serious injury or illness and who need clinical investigations and advanced nursing care. We aim to treat you as quickly as possible. If you would like an approximate waiting time, please ask. In Major Injuries we treat people who have a serious injury or illness. Major Injuries Resuscitation Deliver
  127. 127. People in this area may be at different stages of assessment or treatment. A&E Waiting area This A&E Department is often very busy. We aim to treat everyone as quickly as possible, but waiting times can be long. Thank you for waiting patiently. We see the most urgent cases first. This means that people who arrived after you may be called first. Please ask us if you are worried about waiting times. If you have to leave, please tell us, so that we can update our records. Check in Please take a ticket. Reception staff will call you and ask for details like your name, address, date of birth and next of kin. People who are very unwell may be taken to a treatment room immediately. In this case, a receptionist will be called to the treatment area to complete their registration. At busy times there may be a short wait before your ticket number is called. When the nurse has assessed your injury or illness, we will have a good idea of how serious it is and what type of treatment you may need. We aim to treat the most urgent injuries and illnesses first. We aim to assess you within 30 minutes after check-in. Please wait for your name to be called. A nurse will assess the urgency of your injury or illness and talk to you about the type of treatment you need. Assessment Within each priority category, we treat the most serious cases first. Patients who arrive by ambulance are assessed in the same way as people who arrive unassisted. A specialist nurse, called the triage nurse, will assess the urgency of your injury or illness. Assessment Categories Priority 1 Priority 2 Priority 4 Priority 5 Priority 3 Everyone is assessed using the same scale of priority categories: from 1 (life-threatening) to 5 (non-urgent) Please wait for your name to be called by one of our technicians. Children will be seen first, whenever possible. During busy periods you may have to wait. This unit takes x-rays for A&E and other departments in the hospital. X-Ray Seating area The Major Injuries area is for people who have a serious injury or illness and who need clinical investigations and advanced nursing care. We aim to treat you as quickly as possible. If you would like an approximate waiting time, please ask. Please be aware that it can be difficult to predict waiting times accurately, as some patients take longer to assess and treat than others. In Major Injuries we treat people who have a serious injury or illness. Major Injuries Deliver
  128. 128. Works with frontline staff through reflective practices to support incidents with frustrated, aggressive and sometimes violent patients. Deliver People Solution
  129. 129. Deliver
  130. 130. An online resource offering free high-level design recommendations to help ensure the built environment is optimised for patient comfort. Deliver Toolkit
  131. 131. Deliver
  132. 132. In 2012, the design solutions were installed and piloted at Southampton General Hospital and St George’s Hospital, London. Deliver Installation
  133. 133. Distributing conclusions Evaluating Discover DevelopDefine Deliver Implementation
  134. 134. Discover DevelopDefine Deliver Distributing conclusions Evaluating Implementation Prototyping User Interviews Customer journey walk through Character Mapping Observing Workshops Staff interviews User testingVisualising
  135. 135. Can you identify any service problems or issues within your field? Do you have any ideas how these could be improved using the service design principles? Exercise
  136. 136. Thank you.
  137. 137. DAY 2
  138. 138. A Better A&E Service Design: Innovation for the employed A project led by PearsonLloyd 26-27 October 2015 Brussels European Social Fund ESF project 4985 Vlaanderen is werk
  139. 139. Welcome!
  140. 140. Recap Discover DevelopDefine Deliver Distributing conclusions Evaluating Implementation User testing Prototyping User Interviews Customer journey walk through Character Mapping Observing Workshops Staff interviews Visualising
  141. 141. Deliver Distributing conclusions Evaluating Implementation
  142. 142. Implementation In 2012, the design solutions were installed and piloted at Southampton General Hospital and St George’s Hospital, London. Deliver
  143. 143. Incident Tally This poster is to help you identify the different factors involved in patients and other service users becoming aggressive or violent. The Incident Tally is divided into four sections. Each week you decide what to monitor and write the names in the boxes (refer to the sample tally). When an incident occurs, add it to the tally in the appropriate section.
  144. 144. Based on the investment costs it was important that we proved the designs brought value to the Trusts. Deliver Design value
  145. 145. An evaluation was carried out at the two pilot Trusts to understand whether the solutions improved the patient experience and reduced tensions. Deliver Evaluation
  146. 146. Assumptions Design solutions - Better-informed patient waiting experience - Increased staff capacity to reduce or mitigate aggression and violence - Improved patient experience - Improved staff morale - Reduced staff absenteeism and turnover - Reduced complaints - Improved productivity Reduced incidents Improved outcomes Deliver
  147. 147. The evaluation asked if the solutions: 1. Improved patients’ experiences of A&E? Deliver
  148. 148. The evaluation asked if the solutions: 1. Improved patients’ experiences of A&E? 2. Reduced the amount of hostility, aggression and violence experienced by staff and patients? Deliver
  149. 149. The evaluation asked if the solutions: 1. Improved patients’ experiences of A&E? 2. Reduced the amount of hostility, aggression and violence experienced by staff and patients? 3. Provided good value for money? Deliver
  150. 150. The evaluation entailed patient surveys, staff surveys, ethnographic observations and management interviews. These were designed and conducted by ESRO and Frontier Economics. Deliver Evaluation
  151. 151. of patients said the improved signage reduced their frustration during waiting times. of patients felt the Guidance Solution clarified the A&E process. For every £1 spent on the design solutions, £3 was generated in benefits. Patients’ complaints relating to information and communication fell dramatically post- implementation. Threatening body language and aggressive behaviour fell by 50% post- implementation. Key findings show: Deliver
  152. 152. 88% 82% 78% 75% Patients’ perceptions of the Guidance Solution The signs clarified the A&E process The signs displayed the steps I actually followed during my time in A&E The signs made me feel I could trust that the hospital staff knew what they were doing The signs made the wait less frustrating Deliver
  153. 153. Impact of design solutions on hostility and non-physical aggression Threatening body language or behaviour Raised voice or being shouted at (including hostile or aggressive tone) Offensive language or swearing Uncooperative behaviour -50% -25% -23% -2% Deliver
  154. 154. Primary data collection Pre-implementation Sites Staff survey Patient survey Ethnographic observations Post-implementation Pilot sites (Aug-Sept 2012) Pilot sites (July 2013) Sample size: 120 across both sites Sample size: 143 across both sites Sample size: 93 across both sites Sample size: 107 across both sites Sample size: 593 across both sites Sample size: 553 across both sites yes yes yesno yesno Control sites (Sept & Dec 2012) Control sites (July 2013) Deliver
  155. 155. Cost : Benefit Ratio For every £1 spent on the design solutions was generated in benefits £3 Deliver
  156. 156. Average programme costs Deliver Costs Project Planning £7,000 £12,500 £5,500 £20,000 £11,000 £4,000 Total £60,000 Guidance Solution Expenses People Solution Development Development Implementation Implementation
  157. 157. Average costs and lifespan CostLifespan (years)Equipment Signage 2 Digital Equipment 3 Leaflets 1 £15,000 £2,000 £3,000 Deliver
  158. 158. Secondary data collection August 2011 - August 2012 August 2012 - August 2013 Monthly attendances Monthly attendances Monthly attendances Staff numbers Staff numbers Staff numbers PALS complaints PALS complaints PALS complaints Violence & aggression records Violence & aggression records Violence & aggression records Pilot sites Pilot sites Control sites Deliver
  159. 159. Value For Money framework The framework solely measures the reductions in incidents of psychological stress disorders from reduced aggression. Deliver
  160. 160. Distributing conclusions Evaluating Discover DevelopDefine Deliver Implementation
  161. 161. What next?
  162. 162. Next steps 1. Develop a master plan
  163. 163. Next steps 1. Develop a master plan 2. Get senior management to buy in
  164. 164. Next steps 1. Develop a master plan 2. Get senior management to buy in 3. Engage the workforce
  165. 165. Next steps 1. Develop a master plan 2. Get senior management to buy in 3. Engage the workforce 4. Review current situation
  166. 166. Next steps 1. Develop a master plan 2. Get senior management to buy in 3. Engage the workforce 4. Review current situation 5. Adjust and reinforce
  167. 167. Further implementations have taken place at four Trusts. After initial success in A&E, Southampton implemented the People Solution every department. Implementations
  168. 168. Addenbrooke’s Hospital, Cambridge
  169. 169. Addenbrooke’s Hospital, Cambridge
  170. 170. Newham Hospital, London
  171. 171. Norwich and Norfolk Hospital, Norwich
  172. 172. Royal London Hospital, London
  173. 173. In 2014, the Guidance Solution was launched as a template version allowing Trust to purchase the designs and manage the implementation process themselves. Implementations
  174. 174. Whittington Hospital, London
  175. 175. Airedale Foundation Trust, Keighley
  176. 176. Royal Victoria Hospital, Belfast
  177. 177. South West Acute Trust, Enniskillen
  178. 178. Altnagelvin Area Hospital, Londonderry
  179. 179. Our designs are now implemented in twelve Trusts. The project has garnered interest from more than thirty Trusts from around the world.
  180. 180. Ten key lessons...
  181. 181. 1: Frontline research is crucial
  182. 182. 2: Other industries can unlock new ideas
  183. 183. 3: Some big issues need to be put to one side
  184. 184. 4: Manage expectations
  185. 185. 5: Know how it will benefit you
  186. 186. 6: Embrace the design process
  187. 187. 7: Develop a local response to a universal issue
  188. 188. 8: Link to existing initiatives
  189. 189. 9: Prototyping instead of piloting can help remove barriers to change
  190. 190. 10: Measure the broader impact
  191. 191. Risks, Challenges, Successes...
  192. 192. Risks
  193. 193. Risks, Challenges
  194. 194. Risks, Challenges, Successes...
  195. 195. Happy users Better service Benefits stakeholders Service Design success
  196. 196. Credits: Client: Design Council, Department of Health (UK) Design Team: PearsonLloyd, Tavistock Consulting, Helen Hamlyn Centre for Design, University of the West of England, University of Bath Evaluation Team: Frontier Economics, ESRO Pilot Trusts: St George’s Healthcare NHS Trust, London; University Hospital Southampton NHS Foundation Trust
  197. 197. www.ABetterAandE.com

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