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Redesigning Emergency Ward Operations Andrew Siu Emily Carr University 1399 Johnston Street Vancouver BC, V6H 3R9

ABSTRACT Sometimes what is expressed in theory does not materialize in practice. In these cases, designers need to act resourcefully and turn to other means of gaining research. This paper examines a creative design solution using RFID (radio frequency identification) technology to improve the current system within the British Columbia Children’s Hospital (BCCH) Emergency Ward. The project is an ongoing collaboration between a third/fourth year interaction design course at the Emily Carr University of Art and Design and the BCCH Emergency Ward. Researchers were limited to access and time with stakeholders involved due to ethics and safety. However through a series of interviews, observations and storyboarding techniques, the researchers were able to gain a clear understanding of what defective issues hindered an effective emergency room system. From this research, the project team concluded that the design challenge was much more complex and extended beyond the emergency rooms into other areas of the BC Children’s Hospital. The outcome was a RFID solution to improve interactions between staff and computer terminals located in patient rooms. Keywords interaction, design, hospital, radio frequency identification (RFID), emergency ward INTRODUCTION Currently, there is a growing need for designers to improve services and operations. The challenge of this type of design is recognizing

constraints and all the stakeholders involved within systems and how they interact with one another, leading to in depth research and methodologies to fully grasp concerns that impede an effective operation. But in situations where time and access are limited, there are situations where idealistic design theory does not align itself with design practice. To overcome these obstacles, designers need to remain resourceful and versatile in order to generate meaningful research even if it means looking outside the local environment. Designers can transform given information in order to gain further insight. In volatile environments with many stakeholders involved, how does design research and methodology contribute to critical success factors that need to be considered to improve redesigned operations?

Figure 1: Hospital wayfinding chart BACKGROUND The Emergency ward at the British Columbia Children’s Hospital is searching for innovative

ways to improve current operations in its emergency room. This includes and is not limited to registration, triage, patient monitoring, wayfinding. Our team became specifically interested with the unused computer terminals; tools and resources that could increase hospital efficiency were not being used to its full potential. METHODOLOGY Observation Techniques Prior to our visit to the British Columbia Children’s Hospital Emergency ward, it was decided that individual teams would conduct separate observations and all of the information gathered would later be shared as a whole. During our observations, it was essential that we allow interactions and behaviours to occur naturally to gain the most meaningful information. By ‘melting into the background’ outsiders should have no direct influence on the phenomena under observation. The “method provides detailed, rich insights into the effects of intervention and the influence of context, and is sensitive to the viewpoints of the key actors and the beneficiaries” (Final Materials). However, our group of classmates was a large presence within the hospital setting that could have greatly influenced and disturbed the natural hospital setting. Furthermore, researchers should also carry out ethnomethodological analysis by collecting behaviours and interactions on a daily basis over an extended period of time. But only one formal visit was given by BCCH not allowing researchers to examine consistencies and capture spontaneous data. The limited access also hindered the researcher’s ability to “immerse him/herself in the local environment and culture and to earn acceptance and trust from regular actors” (Final Materials). As a result, our team’s main observations concerning underutilized computer terminals were never fully understood. Ethical issues also prohibited access. Firstly, there are understandable difficulties accessing information from children. Although the intentions of the project is to benefit the experience

for children in Emergency Room services, there are obviously sensitivities gathering opportunistic information from the misfortune of children and distraught parents that enter the hospital. However, this creates a ‘double edged sword’ situation; according to the Tri-Council Policy Statement, “because knowledge of the research can be expected to influence behaviour, naturalistic observation generally implies that the subjects do not know that they are being observed, and hence can not have given their free and informed consent”. In any research situation surrounding ethics, one must consider benefits and risks. The swine flu scare elevated the risk of infection for patients and researchers that convinced the hospital to restrict access to patients and parents.

Figure 2: Entering BCCH Interviews With access and time limitations influencing observation techniques performed, interviews were conducted with a doctor and the IT nurse to effectively understand the system currently in operation. According to Richard Buchanan, participation from primary sources can elicit relevant information; asking participants to sketch diagrams and build collages can help designers understand the “participants’ understanding and perceptions of issues and helps them verbalize complex and unimagined themes.” The participants in this project needed to include children,

parents and hospital staff. Creating a system that would be universal to all types of different users were one of many challenges our design team encountered. The project is also particularly unique because primary stakeholders are patients but the primary source of research is coming from hospital staff. To reconcile any disconnections between the two, interviews with varied patients were performed. And to illustrate all the details, researchers created storyboard techniques to recount experiences of children and parents. This technique helps visualize positive and negative emotive reactions from patients, and could pinpoint at which stage within the system it occurred. Consequently, researchers were able to generate and prepare a richer question bank for the experts at BCCH. Most of the conversations took place with Geoff (one of the doctors who worked in the Emergency Ward) and Liz (one of the nurses in charge of IT). While they were able to answer most of our questions, we generated little feedback from other staff working within the system. Our team specifically wanted to address our concern with the unused computer terminals. Liz’s conclusion was that the authentication process was problematic. Additionally, nurses felt uneasy entering patient information into the hospital system while the patient was still in the room. This is a situation where the ideals and values of co-creation would have been greatly appreciated. In a co-design, the designer takes a passive role in the design process and sacrifices some of his/her duties to the user. “In generating insights, the researcher supports the ‘expert of his/her experience’ by providing tools for ideation and expression” (Sanders). The collective creativity would have been catered to the nurses’ that interact in that space. However, inadequate access to resources within the scope of the project led the team to seek information outside of the project parameters.

The team needed to consult sources independent to BCCH, which precipitated uneasy feelings of seeking general information to solve a unique problem. It was argued, in the end, that the process of accessing different sources (under similar circumstances) is a “good way to illustrate the varied cultural and environmental contexts”(Buchanan). The team found comparable professionals in the same field to interview to broaden the range of insight gathered at the Alberta Children’s Hospital. Our contact was able to provide valuable insight by explaining that nurses were not avoiding patients but were more comfortable within the social setting of the nurse station instead of the patient room. To further elaborate her explanation, she compared the hospital to a restaurant, that wait staff seek solace periodically in the kitchen. With this type of interpretation, we could better recognize what issues hospital staff confront on a daily basis.

Figure 3: Unused terminal in patient room RESEARCH FINDINGS From our research, we determined that the issues with unused computer terminals appeared to be more of a behavioral issue than an authentication issue. The current system have terminals placed conveniently around the Emergency ward but are left unused by hospital staff. Nurses currently push data from two terminals located in the nurses’ station; even a mobile

terminal placed next to the nurses’ station exit was left unused. Information is handled inconsistently as some nurses are more comfortable with technology than others, but a digital data management system would be preferred. Liz informed us that login/logoff process took less than two minutes, yet nurses continued to refuse to logoff and enter patient information from the previous nurse logged on. To help visualize how problematic a simple logon/logoff could create, we constructed diagrams to demonstrate the migration patterns of nurses and the type of traffic congestion it could create in a hectic situation. The diagram also includes a layout of the hospital and illustrates how some of the patient rooms were not within the line of sight from the nurses’ station. Geoff reiterated this issue during the interview process; patient rooms out of sight were barely used. Rough information graphics were also created to simulate how information flows between staff within the Emergency ward and other departments. This method helped conclude that several nurses entering sensitive information under one nurse’s identification not only led to inaccurate statistics but could possibly lead to further risk trying to link nurses to patients.

Foot Traffic Computers

Figure 4: Hospital Foot Traffic Diagram

DIVIDE AND CONQUER Designers were left with yet another challenge: do we design a system that accommodates the nurses’ behaviour or try to break their current pattern? If a new proposed system continued to encourage the nurses’ current authentication pattern, that would mean a redesign of the layout and system of the whole Emergency ward. On the other hand, how do we successfully challenge the current social setting? To settle the debate, our team attempted to strike a balance of three constraints: “feasibility (what is functionally possible within the foreseeable future); viability (what is likely to become part of a successful business model; and desirability (what makes sense to people and for people)” (Brown). The differences eventually divided us into two teams. One team chose a more conceptual “blue sky” approach to demonstrate the future potential of the technology involved; while our team decided it was more feasible and viable to help revitalize staff engagement with the technology already operated in the hospital. Our newly formed team began discussing methods of how the authentication process could be facilitated and more inviting for the users involved. We prioritized our design objectives: entrancing, private, effortless, affable, precision. The concept behind the proposed system is for computer terminals to invite users to interact with its interface (as opposed to users searching for the easiest login). All the while, improving efficiency and documentation of accountability. The next step was to investigate the most fitting type of interactive technology to meet the outlined objectives. TECHNOLOGY INVESTIGATION Using a SWOT analysis (strengths, weaknesses, opportunities and threats), we were able to evaluate abilities and limitations on technologies considered and their impact on the stakeholders involved. “The idea is to maximize opportunities

and minimize threats in the environment while maximizing the advantages of the operation’s strengths and minimizing weaknesses� (Heizer). Therefore, we researched a variety of readers and tags to determine the best interactive authentication system. From our investigation, we quickly eliminated technology in violation with our intended goals. Barcode scanners and an active (long range) radio frequency identification system (RFID) led to privacy and control issues. Conversely, a passive (short range) RFID or biometric technologies did not meet the ease or inviting quality we were also seeking. In the end, we reconciled a passive and active RFID system by implementing a medium range RFID solution.

Medium range RFID Short range RFID

easy to use

easy to use functions without battery useful life of 20 years or more

Long range RFID can read far distances

reading distances privacy

no privacy multiple users activating system

tags can be smaller less expensive to manufacture difficult to replicate

larger tags

controllable durability

more expensive battery outages can lead to misreads


Figure 5: SWOT visual as Venn diagram With a medium RFID, a reader can invite users up to 15 feet away. The frequency of the input tag can also be configured to emit radio frequencies in a linear manner in order to control and specify the user who approaches the terminal. Knowing this, however, we proposed that the reader only project 2-3 feet in order to protect privacy of hospital staff that approaches the computer terminal. The proposed system reinforced authentication security, sustained data accuracy and encouraged accountability. Furthermore, the devices are durable, inexpensive, easy to maintain. We discovered that the technology possessed more potential opportunities than threats. While still controversial, RFID

can detect and output body temperature to help monitor patients. By choosing medium range RFID, original objectives were not sacrificed and ended up becoming more viable. CONCLUSION Even though the ideals of some design theory could not be met, existing methodologies can still be utilized to provide meaningful information to ameliorate systems. In situations where ethics and safety can restrict access, it is for the designer to remain quick-witted with theories and methods to bring control to unpredictable situations. Although observational and interviewing techniques seemed to have contributed little at the beginning, visuals, storyboards and diagrams helped create, enrich and communicate hidden research. Further methodologies were also used to unify collected information where feasibility, viability and desirability were considered for helping decide how to approach design projects. Formalizing ways to analyze internal and external factors quickly and effectively chose which interactive technologies and materials were the most beneficial to the project. By externalizing and making our research more transparent, we realized our research was more significant and influential. As a result, design objectives were not compromised and decisions were justified. REFERENCES 1. Final Materials (2003). Evaluating Socio Economic Development, SOURCEBOOK 2: Methods & Techniques Observational techniques. 1-4 2. Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (2010). SOCS 309 Design Research and Methods. 1-6 3. Buchanan, R (1995). Designing Interactions: Design is the conception and planning of the artificial. People and Prototypes. 4. Sanders, E. (2002). From user-centered to participatory design approaches. In J. Frascara (Ed.), Design and the social sciences: making

connections.(pp. 1-7). London: Taylor & Francis. 5. Brown, T. (2009). Change by Design: How design thinking transforms organizations and inspires innovation. HarperCollins. 6. Heizer, J et al. (2004). Operations Management, Seventh Edition. Pearson Education, Inc. IMAGE REFERENCES Figure 1. Hospital wayfinding chart, Jim Budd (2009) Figure 2. Entering BCCH, Jim Budd (2009) Figure 3. Unused terminal in patient room, Jim Budd (2009) Figure 4. Hospital Foot Traffic Diagram, Zack Marlow-McCarthy (2009) Figure 5. SWOT visual as Venn diagram Andrew Siu (2009)

RFID Hospital Praxis  

A praxis paper on the research and methods used to design a wayfinding system for BC Children's hospital

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