OPEN SOURCE D - Applying a Human-Centric Design Approach to Organisational Systems

NHS X GSA

Product Design Year 3 December 2015

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Introduction

This project is based in an open source environment where everyone has the ability to identify, raise and present solutions to improve determined issues or situations.

GSA x NHS is a collaborative project between third year Product Design students at the Glasgow School of Art and Crosshouse Hospital. As an Open Source project, our aim for the project was to develop a set of tools that requires the application of staff knowledge in order to identify challenges within the area of patient flow.

For this project we worked in groups but collaborated all our findings so that our information was as accurate as possible. Within our studio environment we worked as a class with a flat hierarchy (no one had more power then anyone else) in order to share the workload and produce our deliverables.

Contributors During this project we worked with many hospital staff and the patients seeking care in order to get a range of perspectives. These included nurses, charge nurses, doctors, junior doctors, patients, bed managers, discharge co-ordinator, porters and domestics.

The information we gathered from everyone we observed and interviewed contributed to the entire design process.

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Initial Analysis

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Methods Used

Week

Field Research

Discover & Define

Table of Contents 2

Process

Example

How It Works

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Final Product

47 Deliver

Traingle

Roleplay

Insight Cards

Identifying Opportunities

Mapping Data

Gathering Information

Area of Focus

13 Develop

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Discover & Define

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Discover / define

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Develop

5 Deliver

Field Research Methods Used Initial Analysis

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Field Research We gathered basic information about each area so that we as a class could start to understand the patient flow process.

For our first trip to the hospital we started by attending the morning huddle to see how information is shared after a shift change. We then separated into groups and each covered a different part of the hospital. The areas we went to during this visit were: A&E, cardiology, pharmacy, respiratory, gastroenterology and discharge. We gathered basic information about each area so that we as a class could start to understand the patient flow process.

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Methods Used During our research time at the hospital we used various methods to gather information. We choose to take a very personal approach therefore, spending little time looking at big statistics and more time on personal stories and observations.

Observations One of these methods was observation.

We let staff go about their day as usual and we simply shadowed without interfering whist taking notes and sketching.

This allowed us to gain a more accurate view of what staff do on a day to day basis and how they move around the hospital.

Interviews

We also conducted informal interviews with members of staff. The hospital was very busy so it was difficult at times to obtain the information we wanted but we were incredibly grateful for all the time people spared for us. We also interviewed patients so we could find out how they personally felt their time in hospital had been. This was very valuable to us as it gave us personal perspectives and also allowed us to compare different parts of the hospital.

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Initial Analysis Developing User Journeys After our first visit to the hospital, we began to sort through all the data we had collected. Each group began to build a user journey specific to the area of the hospital they had visited. This meant we could see an overall view of how parts of the hospital worked, who was involved at each stage of a patient’s journey and the feeling at each stage.

These individual would later come together to provide a broad overview of most areas of the hospital. This would lead us to ask better, more informed questions on our second visit to the hospital.

1 Nurse has taken care of patient for a long time.

2 Nurse finishes her shift and goes home.

5 Nurse feels she hasn‘t finished providing the whole patient care ‘package‘.

4 Nurse returns and patient is gone without previous notification.

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3 Patient is discharged and goes home.

Each group began to build a user journey specific to the area of the hospital they had visited. This would lead us to ask better, more informed questions on our second visit to the hospital.

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Develop 1

2

Discover / define

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4

Develop

5 Deliver

Areas of Focus Gathering Information Mapping Data Identifying Opportunities Insight Cards Roleplay Triangle

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Areas of Focus After grouping the information, we came up with new titles for the areas we wanted to focus on during our second visit to the hospital and the rest of the project: A&E, discharge, patient role, pharmacy, communication and trust. We returned to the hospital to gather more in-depth information and ask specific questions for each of these areas. However, our main aim for our second visit was to get more of an idea about staff and patient feeling. This meant we conducted longer interviews to find out personal stories and the reasons behind them.

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TRUST

DISCHARGE

PATIENT ROLE

PHARMACY

COMMUNICATION

A&E

For the second vistit to the hospital, we conducted longer interviews to find out personal stories and the reasons behind them.

Gathering Information We then had a class workshop to map all of this and the previously gathered information in various user journey timelines. We realised each one is unique to the individual but we could group information to particular circumstances to understand the routes people take in the hospital and who is involved at each stage. These journeys could then be analysed to identify where patient flow lost efficiency. We used a process called affinitising which consists of correlating a large amount of information in order to find themes and patterns. This is usually done using headings and post it notes that can be rearranged as more information is added and changed.

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Mapping Data Pat

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Huddle D/C Office Enters Ward Converse at nurse station Compare notes Enquires about patients Look for doc for discharge Aftercare Requirements Doc confirms discharge Discharge Arrangement

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Having found themes and patterns from our collaborative research, our next steps involved visualising these insights in easy-to-understand infographics. The goal of these was to help us more easily digest the masses of data collected as well as help us realise new insights through our mapping.

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Cycle of Work

All the acquired information was used to create infographics so our research could be better understood by ourselves and in turn our client.

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Discharge Info Updated

After Care Peace of Mind

Entry

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S.S.A.

Recovery

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Physiologist

Discharge

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Doctor

Treatment

Patient Peace of Mind - Discharge

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relatives are worried, confused, stressed

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Recovery

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• relatives cannot help the patient

• doesn’t help the patient • waste of doctors time

• longer and bad recovery

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• passive patients • possible waste of time and beds

Discharge

no activity (unnecessary) waiting time bored, frustrated

• no timeplanning is communicated to patient

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no understanding of diagnosis confusion, panic, stess

feeling uncomfortable cannot sleep, relax worried, anxious

Treatment

• no activity • unpleasant, noisy, busy, strange environment

• information is not well fitted to patient

people that don‘t need to go to the hospital

• waste of doctors time (and resources)

Diagnosis

• no additional info given to the family

• people are not aware of their health • not well educated

Entry

Patients Involvement

Reliability

* Data from NHS Report

Discharge Coordinator

Huddle Information

E-Whiteboard System

PMS System

Symphony System

Predictions E-Whiteboard

Bed Manager Report

12 am

3 am

Bed Manager shift begins 6 am

Information Reliability

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12 pm

Disch. Coord.

Ward Rounds End

Peak Information Transfer

Morning Huddle

Disch. Coord.

Ward Rounds End

3 pm

Night Bed Manager shift begins

Afternoon Huddle

6 pm

Disch. Coord.

Shift Ends 9 pm

Perception of patient

Nurse

Discharge coordinator

Ward Whole hospital

The discharge co-ordinator and nurses have a different views about patient flow that bias their decisions. Nurses are focused on patient care in the ward whereas the discharge co-ordinator has an overall view of the hospital.

This is reflected in the difference in language used when speaking about patients; the discharge co-ordinator is more focused on patient flow and the nurses more on patient care.

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Lack of understamding of each others roles Patient

I feel better. I want to go home.

I know the patient very well. I don’t think he should go home yet!

Nurse

Doctor

This patients results are fine but the nurse doesn’t think he is ready to go home.

Understanding Lack of understanding of each others roles.

I need to free up beds and this patient can go home!

His test results are fine!

Discharge coordinator

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Can anyone be discharged?

Is the patient profile filled in?

Yes, but I need a consultant to sign the papers.

No, sorry.

There‘s no time today.

No, what do you need to know?

When can John X go home?

Is the E-Whiteboard up-to-date?

Once S.S.A. and homecare have had MDT meeting.

Discharge Coordinator: Interactions

80% simple

20% complex

discharges

Complex VS Simple Dicharges

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Trust in the system Discharge lounge

I’ll check the information just in case

Manual telephone

The patient is ready to go

There are many systems in the hospital for the transference of information between staff.

Some communication systems don’t provide the right information at the right time due to staff not updating them or not following procedure. Some staff

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E-Whiteboard system update

Ward

members feel more confident about using over another. As a consequence, staff don’t always trust that the correct information is being shown. They use another system to double check the information which slows down the whole process.

Patient medication narrative

Admission check medical history

It is hard to remember everything!

Home

Ward

take medicine

medicine administered

How should I take the medicine?

Patient

What is this medicine for?

I feel overwhelmed.

Too much information!

Discharge

explain home-care

This graph shows an example of a patient‘s journey from admission to home.

It touches upon four areas: admission, being in the ward, discharge and, at home. It describes and addresses the patient‘s concerns regarding medication.

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Pharmacy

home care medicine administration

medical history

diagnosis & label understanding

patient awareness of medication

hostpital care

Patient Awarness All 4 touchpoints are about patient awareness but, at different Stages.

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medical history Pre Hospital

difficulties remembering medical history

patient awareness of medication During Hospital

Some patients do not know what they get some medicines and other medical treatments for

diagnosis & label understanding Every medicine has its own label with information on dosages and administritive guidlines which can make the patient confuesd Post Hospital

medicine administration

Problems

Patient gets confused by the complicated information they receive from doctor

Touchpoints of pharmacy

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The sandwich effect

Doctor

Nurse

Patient

Nurses can feel overwhelmed or ‘sandwiched’ as they have contact with both patients and higher management. Therefore they need to retain a lot of information and act like the middle man constantly transferring it. They serve as the face of the service to the patients.

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Staff interactions with patients

Bed manager discharge coordinator No time

Doctor Twice a day

Nurse Every two hours Patient

Nurses spend the most time with patients and may pick up on subtle behaviours.

However they may become more attached to the patients which influences their decision making. The discharge coordinator sees an overview of the patient and so may not understand why this can affect the nurses’ choices.

This contributes to the gap of communication between the staff.

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Auxiliary Nurse

Staff Nurse

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Communication Channels

Junior Doctor

Consultant

Symphony System

E-Whiteboard System

Desktop Computers

Laptop Computers

PMS System

Landline Telephone

Patient Profile

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Communication - Overview

Staff Access

Social Services

Meal Plans

Archived Patient Files

Online Booking System

Doctor Notes

discharges etc.)

Bed Situation (Free beds, query

Radiology Database

Blood Results

Test Results

Pharmacy

Discharge Transportation

Discharge Coordinator

Bed Manager &

Auxiliary Nurse

Departments & Information Accessible

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Observations

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Nurse Ward Round

Check Bloodwork

Request Archived Files

Reviews Patient File

Consultant-Nurse Review

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Arrival

Updates Notice Boards

Updates E-Whiteboard

Assessment by Nurse

Arrival in Ward

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Communication - Inpatient Cycle of Care

Ward Round

Homecare

Transport

Consultant

Medication

Critically-Led Discharge

Test Results & Diagnosis

Book Test

Update Consultant Notes & Files

Talk to Patient

Check Observation Clipboard Cycle of Care

Discharge

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Location

Ward 4F (intensive)

Who

Junior doctor

Surgery

Nurse

Senior doctor

Communication

Pager

Whiteboard info

Problems

Patients too ill to communicate

Other

Aware that hospital is outside peoples’ comfort zone

Aware of patient journey

Relatives involved in cares

Adopt certain posture, attitude when at work

Active staff support

Design Opportunities

Communication between relatives and nurses

Quotes

Aware that hospital is outside peoples’ comfort zone

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»I’ve got the feeling that I am not giving enough care to patient, but when I see feedback it is all about hospital, not nurses.

I guess patients are happier than I imagine.«

Ward 4E (general)

Discharge lounge

Nurse

Bed manager

Relatives

Porter

Junior doctor

Senior doctor

Discharge coordinator

Lounge admin

Whiteboard info

Phone call informatic system

Discharge script Discharge booklet

Perception of care Whiteboard not often updated

Bed manager on top of the hospital organisation

Perception of job for nurses

Disagreement about complex patient discharge

Not always a doctor available to sign patient’s discharge

Basic feedback sheets given to patients

Trust

Discharges are customised

Communication nurses/discharge coordinator/bed manager

»When I have to discharge, nurses feel the whole package of care hasn’t been provided.«

No trust in the electronic system

Close environment, transition to go home

Discharge delay for patient’s comfort

»I always have to phone the ward to be sure electronic information is right and complete«

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Entry

Diagnosis

Treatment

Stress

Happiness

Understanding

Waiting

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Recovery

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Bored

Given too much info to digest

Unsure of what is next.

How long to wait

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Tired Frustrated

Annoyed

Stressed Scared

Overwhelmed

Relieved

Stressed Scared

Patient feeling

Discharged

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Attended to by nurse throughout day

Nurse settles patient

Porter moves patient to a new ward

Admitted

Treatment or treatment plan

More depth tests & diagnosis

General tests & diagnosis

Describe issue

Backstage

Diagnosis

Family wastes Doc’s time with Q&A

Organise bed or discharge progress

Process results

Assigned priority

Receptionist puts in info (general, specific)

Patient view

Check in Treatment

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Staff collect meds from pharmacy

Secretary checks patients out

Jr. doc. prints off medication for pharmacy

Family – Doctor communication

Jr. doc. uploads info

Request for home-care written in file

Nurses fill out paperwork in corridors

Documentation of tasks with patients during day

Can patients do something more productive with time?

Bored

Doesn’t trust nurse to answer questions

Happy

Impatient Frustrated

Grateful Happy

Stressed Scared

Releived

nsp Tra

ort

Home

Picked up by family or friends, or hospital arranged transport

Waits to be picked up

Porter moves patient to discharge

Patient monitoring Nurse / Junior Doc. / Senior Doc.

Porter moves patient to a recovery ward

Middle grade or senior doctor ward round

Recovery Discharge

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Identifying Opportunities

Interviews

Insights & Opportunities Mapping Journeys

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Observation

When it came to identifying opportunities, we wanted to make sure we had a range from all six groups.

We therefore gathered five illustrated insights from each group and presented them to the class so that everyone was aware of all the findings. A group of people then returned to the hospital in order to check the accuracy of these insights from the areas they were gathered. As a lot of our insights were based on feelings within the hospital and between staff, it was difficult to decide whether they applied to many people or were very specific. Adjustments were then made according to the updated information that was brought back and from these, we were able to start developing our tools.

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Nurses are too busy caring for patients to fill out paperwork and update E-whiteboard. Leads to incomplete information.

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After we identified possible opportunities, a group of people returned to the hospital in order to check with the staff the accuracy of these insights from the areas they were gathered.

Lack of trust in the E-system leads to information being double checked.

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To display our insights in the clearest way possible, we choose to design a set a cards. They represent the main issues that each group identified during their research in the different areas of the Hospital. They represent not only problems, but also design opportunities to improve the patient flow in the hospital. Each contains a scenario of an issue and the respective personas that interact in that situation.

They are organised in three different colours that represent three categories of issues: Red for patient issues Salmon for issues between staff and staff Blue for issues between staff and patients These insights work as a tool to help the hospital improve its communication flow, trust and accuracy.

Insight Cards

Each Insight Card contains a scenario of an issue and the respective personas that interact in that situation.

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From our research we found that, at times, there seemed to be a lack of empathy and understanding between staff. In that sense,developed a role-play game that allows staff to address issues within the hospital by engaging with each other and talking them through.

We developed scenarios based on our insights that can be acted out so that the issues. These are an alternative to the insight cards that allow staff to identify the issue and the root of these issues themselves. The process of the role-play is in the form of a booklet so that is easy to follow and understand. Our hope is that the essence of the role-play can be used in the wards to quickly put staff in others shoes to help the understanding of issues in different roles.

The next tool we developed allows staff to design outcomes to solve issues identified in the roleplay.

Roleplay

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Triangle The Triangle of Communication is a tool that we developed to help the hospital staff to break down communication issues and find opportunities for design.

It works as a complementary tool to the roleplaying game helping discussion among participants.

The tool is made of a drawing of a triangle that represent three elements that ensure good communication: Understanding, Knowledge and Trust.

Each vertex represents the maximum score of each element. Users can then evaluate each of the key aspects of communication after and give them a score from 1 (bad) to 10 (good) based

on the following questions: Knowledge: How accurate was the information?

Understanding: How clearly was the information transmitted?

Trust: How well did people rely on the information that was being passed?

Once the users have given scores to each element, a new triangle is formed by joining the dots that reveals the areas where users can work on solutions.

Aim: Without good communication processes follow a different path than intended. Within communication there are three elements: Understanding, Trust, and Knowledge. This tool helps you identify which of these elements have room for development.

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How to Draw the Triangle?

1. To evaluate each element, ask yourself in a scale from 1 to 10:

3. Connect the dots with lines.

UNDERSTANDING

A. Knowledge: How accurate was the information?

B. Understanding: How clearly was the information transmitted?

C. Trust: How well did people rely on the information that was being passed?

2. Draw dots in the lines with the values of each element.

KNOWLEDGE

TRUST

4. If the corners of your drawn triangle, are close to the center, then these are the elements that need improving.

UNDERSTANDING

UNDERSTANDING

KNOWLEDGE

TRUST

KNOWLEDGE

TRUST

5. Use the triangle to discuss where could communication be improved.

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DELIVER 1

Discover / define

2

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Develop

5 Deliver

Final Product How it Works Example:

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Final Product The final product we have developed is a set of tools that should be used in conjunction with hospital staff. The insights we have gathered are only a starting point to build on and to help people see how they can think about other issues they themselves have identified within the hospital.

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EXAMPLE:

The triangle represents the best possible communication. All three elements got the highest score (10).

(1) Bad (10) Good The lines in the middle represent a scale from 1 - 10 for each elemtent, from bad (the centre) to good (the end of the lines).

Scenario: Alex told his friend Sam to come to the party sometime in the evening. He expected Sam to arrive at 8 but Sam arrived two hours late.

Discussion: — “I think Alex and Sam trust each other because they’re long-time colleagues... we can give Trust an 8” — “Their Understanding seemed to be quite good since they both knew there was a party. It’s a good 7” — “But Alex didn’t was a bit vague about time. He never told Sam the specific time. Let’s give Knowledge a 3. There is an issue here that we can work on”

The new triangle that you have drawn represents comminucation in the scenario.

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Create Your Own Although we carried out research in the hospital, we weren’t able to spend a lot of time there. We also went in a fairly personal direction and therefore, a lot of our insights are based on individuals’ opinions and stories. This means that other members of staff may want to note down their own experiences to discuss and these templates facilitate this. The research we conducted can be carried on, developed and added to by members of the hospital who have more in-depth knowledge of patient flow.

The ‘Identify scenarios’ booklet enables users to identify and record issues in the hospital environment. By doing this you create a platform where you can begin to understand an issue. We use this tool to understand different perspectives on the issue, understanding these different perspectives gives you a true representation of what is happening around the hospital.

After identifying issues, staff can then put their problems into blank versions of our outcomes. These allow staff to make their own insight cards and scenarios for role-play.

Building on the understanding of the issues using insight cards and the roleplay, you can begin to brainstorm ideas on how to provide a solution to the problem By asking “How can we?” or “How might we?” you can create a discussion around the issue and how you are able to solve it. Viewpoints from different professions provide an array of possible solutions.

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After five weeks of hard work, late nights, miscommunication and a whole heap of optimism, we have arrived with a combined outcome that we are all proud of. We have learnt a lot about field research and about service design but the thing we have struggled most with, and hence learnt the most about, is teamwork. It hasn’t been easy, but who said working with your 30 of your friends in a flat hierarchy would be?

It has been a constant battle to design with a shared vision class vision and not just with a small committee. Sitting here and writing this in a studio that more resembles a war room then classroom, it’s amazing to think how motivated and hard working everyone is. We have truly come together as a year group to produce something we see as realistic and that we are proud of.

We really hope that the tools we provide are of use to the staff of Crosshouse Hospital and will help them to better understand where, when and why problems with patient flow arise.

Conclusion

We would like to thank everyone who helped us during the project. We are extremely grateful to all the staff in the hospital who took time out of their busy schedules to help us with any questions we had. They provided us with crucial knowledge that made this job possible.

Finally, we would like to thank Dr Hans Hartung and Karen Bell who facilitated this project and were our points of contact throughout the five weeks, always available and receptive to our queries and suggestions.

We are extremely grateful to all the staff in the hospital. They provided us with crucial knowledge that made this job possible.

We would also like to thank our tutors Stuart Bailey and Ian Grout as well as Jamie Sunderland who was our guest tutor during the project.

Thank You! 52

Team: Diane Arnold Graeme Bell Lena Clasing Mor Dagan Luis de Sousa Jana Dreyer Moritz Ebeling Luisa Felappi Imogen Foulkes Maximillian Hans Ashleigh Jamieson Anna Jannas Amalie Kvistgaard Laura MacDonald Ross McIntosh Lia Barahona Morales Alexander Nielsen Alexander O’Neill Charline Roussel Greg Smith Alexandra Steenbeek Kirsten Stewart Peter Swanton Santiago Taberna Satsuki Tanaka Braden Tinline Franziska Waldschmidt Mai Watanabe Fred Wordie Xuanyu Zhang

Contact: Stuart Bailey s.bailey@gsa.ac.uk

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NHS X GSA