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

PearsonLloyd
An award winning
industrial design and
innovation consultancy
based in London.

Our Work
Workplace
Healthcare Aviation Public Realm
Product Hospitality

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.

User engagement
Stakeholders and
systems
Multidisciplinary
teams
Design-led
innovation
Design-led innovation

What?
Curiosity : What people
need and want
SERVICE DESIGN

What?
need and want
Imagine and dream up a
better future
SERVICE DESIGN

What?
need and want
Imagine and dream up a
better future
Find ways to do something
about it
SERVICE DESIGN

What?
You have to be there
SERVICE DESIGN

You have to be there It happens overtime
What?
SERVICE DESIGN

You have to be there It happens overtime You don’t own it but use it
What?
SERVICE DESIGN

Human empathy
What?
SERVICE DESIGN

Human empathy Holistic thinking
What?
SERVICE DESIGN

Human empathy Holistic thinking Experience prototyping
What?
SERVICE DESIGN

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

Purpose : Creating mutual value
- USEFUL
- USABLE
- DESIRABLE
- EFFECTIVE
- EFFICIENT
- DIFFERENT
Provider UserService
Design

- Better customer experience
- Reduced costs
- Increased return on investment
- Great new opportunities
What does Service Design lead to?

Public Private
Service Design sectors

What does Service Design
look like?

No Red Tape: Young Taxpayers
by MindLab

The Good Kitchen
by Hatch & Bloom

Popup Parks (part of Knee High
project) by Tom Doust

Improving train platform info
by STBY

Department of Health
NHS
Specialist CarePrimary Care
GPs Hospitals Urgent Care Centres
UK Healthcare

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

To reduce levels of violence and
aggression towards staff in Accident
& Emergency departments.
The Challenge

Problem
Intangible Tangible
Solution
Design Process
The Challenge

Exercise 1:
Design process
Working in groups use the
cards provided to understand
the design process.

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

Tools
Discover
Observing Workshops

Tools
Discover
Observing Workshops Staff interviews

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

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

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

Perpetrator characteristics:
Clinically confused/
Socially isolated
FrustratedIntoxicated Anti-social/
Angry
Distressed/
Frightened
Discover

Discover
Triggers of violence or aggression:
- Clash of people
- Lack of progression/
perceived inefficiency
- Unsafe and inhospitable
environments
- Intense emotions
- Inconsistent response
- Staff fatigue

Understanding violence and
aggression in A&E
Triggers & escalators
Emotional state
Individual characteristics
Tolerance threshold
Needs & motivations
Discover

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

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

The brief
User-centred
process
Discover

The brief
Versatile spaces
Discover
User-centred
process

The brief
A good wait
Discover
Versatile spaces
User-centred
process

The brief
Perceptions
of A&E
Discover
A good waitVersatile spaces
User-centred
process

The brief
Making safe
Discover
Perceptions
of A&E
User-centred
process

The brief
Discover
Place and
process clarity
Making safe
Perceptions
of A&E
User-centred
process

The response
Discover
Place and
process clarity
Making safe
Perceptions
of A&E
User-centred
process

Discover
Exercise 2:
Stakeholder map
Who were the stakeholders for this
project? Use the worksheet to map
out who you think was involved.

Exercise 2 : Stakeholder map
Fill in the map according to the four categories of stakeholders.
We will then share together.
Institutions
People
Designers
Staff

Institutions
People
Designers
Staff
Discover
Stakeholders

patients
doctors
product
service
graphicNHS
Dept of Health
Design Council
hospitals
medical
nurses
reception
security
visitors
family
Discover
Stakeholders
Institutions
People
Designers
Staff

Discover
Observing
Workshops
Staff
interviews

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

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

Tools
Define
The process: expectation
Arrive TreatO utcomePatient
User
The system
The process: reality
Arrive
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

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

The design team conducted their
own research to understand the
user and staff perspectives.
Define
Research

The systemMe
versus
Patients and other service users
often lack knowledge about how
the A&E system works.
Define
A&E System

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

ARRIVAL
PEOPLE
Improving staff
interactions
Positive
first impression
Making it
bearable
Keeping patients
informed
GUIDANCE
WAIT
Define
Four themes

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

Where do
I park?
Where’s the
entrance?
What’s this
queue for?
Should I
be here?
Arrival:
A chain of negative experiences
Define

Arrive Treat OutcomePatient
User The system
Wait:
Patient expectation of process
Define

Arrive
Book in Assess Monitor Treat Outcome
Wait:
Reality of patient process
Patient
User The system
Define

Wait:
Patient perception of process
Wait
Arrive Book in Assess Monitor Treat
Wait Wait Wait Wait Outcome
User The system
Define
Patient

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.
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.
happen to me.
I feel safe.
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.
Guidance:
Ideal patient experience
Define

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

PHYSICAL
High level
VERBAL
Low level
AGGRESSION
FRUSTRATION
VIOLENCE
Prevention Intervention
Define
Guidance:
Prevention vs. Intervention

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

Define
Communication Service Environment
People:
Integrated service
Working with staff to deliver a better service

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

Define
Exercise 3:
Character mapping
Using the worksheet, try to understand what
the characteristics and mindset of a potential
perpetrator might be.

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:

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

Discover Define
User
Interviews
Customer
journey walk
through
Character
Mapping

- 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

Tools
Prototyping Visualising
Develop

Tools
Prototyping User testingVisualising
Develop

Design essentials
It was crucial for the solutions to be:
– Easily implementable
– Non-Trust specific
– Retrofittable
– Flexible
– Affordable
– Effective
Develop

Exercise 4:
Patient journey
Develop
Using the worksheet provided to map
a patient’s journey through A&E.

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

Entrance Meet & Greet
Waiting room: Process MapReception
Develop
Visualising

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

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
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

Reflection
Learning Reporting
RECOVERY
Staff solution
Develop

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

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
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
attention. Often
may look unkempt,
personal hygiene.
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
ANTISOCIAL / ANGRY
incident
reports
A&E
Culture
Intro
A&E
Structure
Home
Patient
types
RESPONSE
Individuals who may
be without a
diagnosable medical
attention. Often
may look unkempt,
personal hygiene.
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

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

INCIDENT DIARY
INTOXICATED CLINICALLY
CONFUSED
SOCIALLY
ISOLATED
DISTRESSED FRUSTRATED ANTISOCIAL
Mark each time a patient/visitor is aggressive or violent:
DATE:
SOCIAL
Develop
Reporting

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

Prototyping
Discover DevelopDefine
User testingVisualising

Discover DevelopDefine Deliver

Objectives
- Taking product or service to launch.
- Ensure customer feedback
mechanisms are in place.
- Share lessons from development
process back into the organisation.
Deliver

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

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

The team created a three-pronged
set of design solutions tailored
to the different needs of patients
and staff.
Deliver
The solutions

PEOPLE
INFORMATION
IMPLEMENTATIONImproving staff
interactions
Keeping patients
informed
GUIDANCE
Deliver
TOOLKIT
Free design
recommendations
The solutions

An information package that guides
patients through A&E, ensuring
they have information about the
department and how it works.
Deliver
Guidance Solution

OutcomeTreatmentAssessmentCheck in
Deliver

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

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
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

Walk in
Ambulance
The receptionist
will check you in.
For people whose
injuries can be assessed and
treated in one step.
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
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.
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
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

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
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
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

Works with frontline staff through
reflective practices to support
incidents with frustrated, aggressive
and sometimes violent patients.
Deliver
People Solution

An online resource offering free
high-level design recommendations
to help ensure the built environment
is optimised for patient comfort.
Deliver
Toolkit

In 2012, the design solutions were
installed and piloted at Southampton
General Hospital and St George’s
Hospital, London.
Deliver
Installation

Distributing
conclusions
Evaluating
Implementation

Distributing
conclusions
Evaluating
Implementation
Prototyping
User
Interviews
Customer
journey walk
through
Character
Mapping
Observing
Workshops
Staff
interviews
User testingVisualising

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

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

Recap
Distributing
conclusions
Evaluating
Implementation
User testing
Prototyping
User
Interviews
Customer
journey walk
through
Character
Mapping
Observing
Workshops
Staff
interviews
Visualising

Deliver
Distributing
conclusions
Evaluating
Implementation

Implementation
In 2012, the design solutions were
installed and piloted at Southampton
General Hospital and St George’s
Hospital, London.
Deliver

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.

Based on the investment costs it
was important that we proved the
designs brought value to the Trusts.
Deliver
Design value

An evaluation was carried out at
the two pilot Trusts to understand
whether the solutions improved
the patient experience and
reduced tensions.
Deliver
Evaluation

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

The evaluation asked if the solutions:
1. Improved patients’ experiences
of A&E?
Deliver

of A&E?
2. Reduced the amount of
hostility, aggression and violence
experienced by staff and patients?
Deliver

of A&E?
2. Reduced the amount of
hostility, aggression and violence
experienced by staff and patients?
3. Provided good value for money?
Deliver

The evaluation entailed patient
surveys, staff surveys, ethnographic
observations and management
interviews. These were designed
and conducted by ESRO and
Frontier Economics.
Deliver
Evaluation

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

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

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

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

Cost : Benefit Ratio
For every £1 spent on
the design solutions
was generated
in benefits
£3
Deliver

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

Average costs and lifespan
CostLifespan (years)Equipment
Signage 2
Digital Equipment 3
Leaflets 1
£15,000
£2,000
£3,000
Deliver

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

Value For Money framework
The framework solely measures
the reductions in incidents of
psychological stress disorders
from reduced aggression.
Deliver

Next steps
1. Develop a master plan

Next steps
2. Get senior management to buy in

Next steps
3. Engage the workforce

Next steps
4. Review current situation

Next steps
4. Review current situation
5. Adjust and reinforce

Further implementations have
taken place at four Trusts. After
initial success in A&E, Southampton
implemented the People Solution
every department.
Implementations

Addenbrooke’s Hospital, Cambridge

Norwich and Norfolk Hospital, Norwich

In 2014, the Guidance Solution
was launched as a template
version allowing Trust to purchase
the designs and manage the
implementation process themselves.
Implementations

Airedale Foundation Trust, Keighley

Royal Victoria Hospital, Belfast

South West Acute Trust, Enniskillen

Altnagelvin Area Hospital, Londonderry

Our designs are now implemented
in twelve Trusts. The project has
garnered interest from more than
thirty Trusts from around the world.

1: Frontline research is crucial

2: Other industries can unlock new ideas

3: Some big issues need to be put to one side

5: Know how it will benefit you

7: Develop a local response to a universal issue

8: Link to existing initiatives

9: Prototyping instead of piloting can help remove
barriers to change

10: Measure the broader impact

Risks, Challenges, Successes...

Happy
users
Better
service
Benefits
stakeholders
Service Design success

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

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

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