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

PearsonLloydAn 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.

What’s behind a design?

Design thinking

Design innovation

User engagement

Stakeholders and systems

Multidisciplinary teams

Design-led innovation

Design-led innovation

What?

SERVICE DESIGN

What?

Curiosity : What people need and want

SERVICE DESIGN

What?


Imagine and dream up a better future

SERVICE DESIGN

What?


Imagine and dream up a better future

Find ways to do something about it

SERVICE DESIGN

SERVICE DESIGN

What?

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

SERVICE DESIGN

What?

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

Valu

e fo

r pro

vide

r

EXPERIENCE

SERVICE

PRODUCT

COMMODITY

Purpose : Creating mutual value

- USEFUL- USABLE- DESIRABLE

- EFFECTIVE- EFFICIENT- DIFFERENT

Provider UserServiceDesign

- Better customer experience- Reduced costs

- Increased return on investment- Great new opportunities

What does Service Design lead to?

Public Private

Service Design sectors

Public Private

Service Design sectors

What does Service Design look like?

No Red Tape: Young Taxpayersby MindLab

The Good Kitchenby Hatch & Bloom

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

Improving train platform infoby STBY

A Better A&Eby PearsonLloyd

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

Design Process?

Process

Exercise 1:Design process

Working in groups use the cards provided to understand the design process.

Double Diamond process

Discover

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

Tools

Discover

Observing Workshops

Tools

Discover

Observing Workshops Staff interviews

Defining the problem

Discover

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 aggressionIn

crea

sing

sev

erity 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-centredprocess

Discover

The brief

Versatile spaces

Discover

User-centredprocess

The brief

A good wait

Discover

Versatile spacesUser-centredprocess

The brief

Perceptions of A&E

Discover

A good waitVersatile spacesUser-centredprocess

The brief

Making safe

Discover

Perceptions of A&E


The brief

Discover

Place and process clarityMaking safePerceptions

of A&E


The response

Discover

Place and process clarityMaking safePerceptions

of A&E


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 mapFill 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

graphicNHSDept of Health

Design Council

hospitals

medical

nurses

reception

security

visitors

family

Discover

Stakeholders

Institutions

People

Designers

Staff

Discover

Observing

Workshops

Staff interviews

Discover Define

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

User interviews

Tools

Define

The process: expectation

Arrive TreatO utcomePatient

UserThe system

The process: reality

Arrive

Wait Wait Wait Wait Wait

Book inA ssessM onitor TreatO utcomePatient

UserThe system

The process: user perception

Wait

Arrive Book inA ssessM onitor Treat

Wait Wait Wait Wait OutcomePatient

UserThe system

Customer journeyUser interviews

Tools

Define

The process: expectation

Arrive TreatO utcomePatient

UserThe system

The process: reality

Arrive


Book inA ssessM onitor TreatO utcomePatient

UserThe system

The process: user perception

Wait

Arrive Book inA ssessM onitor Treat

Wait Wait Wait Wait OutcomePatient

UserThe 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 FrustratedIntoxicated &

Socially isolatedClinically 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 TavistockInstitute

ChesterfieldHospital

Guy’s and St Thomas’ Hospital

SouthamptonHospital

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 patientsUnrealistic patient expectationsDisorientationPoor waiting environmentOvercrowding/lack of spaceOther environmentLack of privacyNoisyDrunk/Mentally ill patientsPatient flow through departmentPoor customer serviceLack of securityAnxiety for themselves or others

Give patients information (times/process)Staff welcoming roleBetter signageEncourage positive feedbackImprove layoutSeperate aggressive patientsDecor/lightingImprove staff facilitiesReduce clutter in arrival areaFacilities/distractions in waiting areaAccess controlSafe storageEducation for staffSecurity presence in A&ECCTVSupport for staffTea trolley

Lack of information for patients

Unrealistic patient expectations

Disorientation

Poor waiting environment

Overcrowding/lack of spaceOther environmentLack of privacyNoisy

Drunk/Mentally ill patientsPatient flow through department

Poor customer service

Lack of security

Anxiety for themselves or others

Give patients information (times/process)

Staff welcoming roleBetter signageEncourage positive feedbackImprove layoutSeparate aggressive patientsDecor/lighting

Improve staff facilitiesReduce clutter in arrival area

Facilities/distractions in waiting areaAccess controlSafe storageEducation for staff

Security presence in A&E

CCTV Support for staffTea trolley

Detailed research

ARRIVAL

PEOPLEImproving 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.


Wait

I understand the service and what happens next.

I know why I am waiting.

I know what I am waiting for.

I know how long I’ll wait.

I am free to wait in a manner that suits me.

I know I haven’t been forgotten.

I can find out more if I’m not sure.

I’m comfortable.


I feel safe.


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.


Monitor/Treat

I understand what’s next in my journey.

I know why I’m waiting.

I know what I’m waiting for.

I know how long I’ll wait.

I am comfortable.

I know I haven’t been forgotten.

I can find out more if I’m not sure.


I feel 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

VERBALLow level

AGGRESSION

FRU

STRATION

VIOLEN

CE

Prevention InterventionDefine

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 : PersonaCreate 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 FrustratedIntoxicated &

Socially isolatedClinically 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

Discover DevelopDefine

- 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

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

Develop

Develop

Exercise 4: Patient journey

Develop

Using the worksheet provided to map a patient’s journey through A&E.

Exercise 4 : Patient journeyMap 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

Develop

Patient Journey

Develop

Develop

Develop

Develop

Department overview

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 throughtothedifferentspaces.

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 throughtothedifferentspaces.

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: [email protected]

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 MatronA&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 : ListenListen 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 : EmpathiseThe 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 : ProposeOnly 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 handWORKING 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&ESocially isolatedIndividuals 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 toact 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 tolisten and be difficult to reason with. Individuals may be unusually volatile and unpredictable.

Antisocial/angryIndividuals 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.

IntoxicatedIndividuals 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.

FrustratedIndividuals 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 confusedIndividuals 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

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Som

e m

ay m

ake

thei

r fru

stra

tion

clea

r lon

g be

fore

they

wou

ld re

sort

to v

iole

nce

or a

ggre

ssio

n; o

ther

s

may

sim

ply

‘eru

pt’ w

ith se

emin

gly

no a

dvan

ce w

arni

ng a

t all.

Inde

ed, i

t

may

also

take

the

indi

vidu

al b

y

surp

rise

– a

mom

enta

ry lo

ss o

f

cont

rol o

r im

paire

d ju

dgem

ent.

INTOXIC

ATED

Indivi

duals w

ho

are dru

nk or

otherw

ise

into

xicat

ed and

may

have

dimin

ished

self-

contro

l or

perceptio

n of the

conse

quences o

f

their a

ctions.

Drinkin

g alco

hol

and ta

king so

me dru

gs can

reduce

people’s so

cial a

nxietie

s and

mak

e the drin

ker le

ss lik

ely to

worry

about t

he conse

quences o

f his

or

her acti

ons.The effe

cts of a

lcohol o

n cogniti

ve

functi

oning m

ay re

duce th

e

indivi

dual’s a

bility t

o proce

ss or

rem

ember e

ven bas

ic in

structi

ons

or solve

sim

ple problem

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 re

ason, these

individuals may not be in control of

their behaviour or th

eir 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 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 in a visibly panicked state.


DISTRESSED / FRIGHTENED

Individuals with

a tendency owards violent

aggressive behaviour and a

far lower threshold

for responding to

triggers.There are no easy

ways to detect

‘anti-social’ people.

They may take an aggressive stance,

swear excessively, or speak in a loud

voice.They are likely to be ‘antisocial’ in a

variety of contexts and may also act

in a negative or abusive way in the

absence of triggers. It is more likely

that these individuals have little

respect for any kind of authority or

rules, and may be unafraid of the

consequences of behaving badly.

ANTISOCIAL / ANGRY

FRU

STRA

TED

Indi

vidu

als

who

ar

e co

nsid

ered

‘re

ason

able

’ w

hen

first

pr

esen

ting

at

A&E,

but

who

are

dr

iven

pas

t the

ir to

lera

nce

thre

shol

d by

the

trig

gers

and

es

cala

tors

they

ex

perie

nce

whi

le in

the

A&E

envi

ronm

ent.

Som

e m

ay m

ake

thei

r fru

stra

tion

clea

r lon

g be

fore

they

wou

ld re

sort

to v

iole

nce

or a

ggre

ssio

n; o

ther

s

may

sim

ply

‘eru

pt’ w

ith s

eem

ingl

y

no a

dvan

ce w

arni

ng a

t all.

Inde

ed, i

t

may

als

o ta

ke th

e in

divi

dual

by

surp

rise

– a m

omen

tary

loss

of

cont

rol o

r im

paire

d ju

dgem

ent.

INTOXI

CATEDIn

dividua

ls who

are d

runk o

r

other

wise

into

xicat

ed an

d

may

have

dimin

ished

self-

contro

l or

perc

eptio

n of t

he

conse

quen

ces o

f

their

actio

ns.

Drinkin

g alco

hol

and ta

king s

ome d

rugs

can

reduc

e peo

ple’s

socia

l anxie

ties a

nd

mak

e the

drin

ker l

ess l

ikely

to w

orry

about

the c

onsequ

ence

s of h

is or

her a

ctio

ns.The

effe

cts o

f alco

hol o

n cogn

itive

funct

ionin

g may

reduc

e the

indivi

dual’s

abilit

y to pr

ocess

or

rem

embe

r eve

n basic

inst

ruct

ions

or solve

sim

ple pr

oblem

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 re

ason, these

individuals may not be in control of

their behaviour or th

eir 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 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 in a visibly panicked state.


DISTRESSED / FRIGHTENED

Individuals with

a tendency owards violent

aggressive

behaviour and a

far lower threshold

for responding to

triggers.There are no easy

ways to detect

‘anti-social’ people.

They may take an aggressive stance,

swear excessively, or speak in a loud

voice.They are likely to be ‘antisocial’ in a

variety of contexts and may also act

in a negative or abusive way in the

absence of triggers. It is more likely

that these individuals have little

respect for any kind of authority or

rules, and may be unafraid of the

consequences of behaving badly.

ANTISOCIAL / ANGRY 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

SOCIALLY ISOLATED

incident reports

A&ECulture

Intro

A&E Structure

Home

Patient types

RESPONSE

Individuals who may be without a diagnosable medical problem and consider A&E a place of safety and a way to receive attention. Often regular attenders at A&E, these individuals may look unkempt, unstable, or have poor personal hygiene.

While often harmless, these individuals can be manipulative or threatening at times.

Their knowledge of the system can be used to get around basic security measures. Personal knowledge of staff that has been built up over time can make their behaviour more distressing and vivid.

SOCIALLY ISOLATED

“Why are you letting that woman in before me!?”

Tone of voice: Assertive, reasoning

Response:

Body language:

INTOXICATED

Individuals who are drunk or otherwise intoxicated and may have diminished self-control or perception of the consequences of their actions.

Drinking alcohol and taking some drugs can

reduce people’s social anxieties and make the drinker less likely to worry about the consequences of his or her actions .

The effects of alcohol on cognitive functioning may reduce the individual’s ability to process or remember even basic instructions or solve simple problems.

RESPONSE

“ Get your filthy hands off me. My leg hurts and I’m

trying to sleep.”

Develop

Staff Perspective

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?

PersonalityPain/Anxiety

Quality of serviceEnvironmental 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

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%

Evaluating

Deliver

Implementation

Tools

88% 82% 78% 75%



-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

TOOLKITFree 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

Deliver

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

Please take a ticket.

Reception staff will call you and ask for details like your name, address, date of birth and next of kin.

At busy times there may be a short wait before your ticket number is called.

People who are very unwell may be taken to a treatment room immediately. In this case, a receptionist will be called to the treatment area to complete their registration.

Check-in Assessment Treatment Outcome

Deliver

Walk in

Ambulance

The receptionist will check you in.

For people whose injuries can be assessed and treated in one step.

A nurse will assess the urgency of your injury or illness.

Most people will be able to leave A&E after treatment.

For people with very urgent injuries or illnesses.

We may need to find out more about your injury or illness.

People who need further treatment will be admitted to a hospital ward.

For people with less urgent injuries or illnesses.

You will be treated in order of urgency.

You will be seen by a nurse in order of arrival.

You may have to wait while we process your test results and decide on the best treatment.

Tests

Handover

Check in

Hospital

Assessment Leave A&E

Major Injuries

See & Treat

Minor Injuries

People in this area may be at different stages of assessment or treatment.

A&EWaiting 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



People who are very unwell may be taken to a treatment room immediately.


When the nurse has assessed your injury or illness, we will have a good idea of how serious it is and what type of treatment you may need.

We aim to treat the most urgent injuries and illnesses first.

We aim to assess you within 30 minutes after check-in.

Please wait for your name to be called.

A nurse will assess the urgency of your injury or illness and talk to you about the type of treatment you need.

Assessment

Within each priority category, we treat the most serious cases first.

Patients who arrive by ambulance are assessed in the same way as people who arrive unassisted.

A specialist nurse, called the triage nurse, will assess the urgency of your injury or illness.

AssessmentCategories

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-RaySeating 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&EWaiting 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



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.


When the nurse has assessed your injury or illness, we will have a good idea of how serious it is and what type of treatment you may need.

We aim to treat the most urgent injuries and illnesses first.

We aim to assess you within 30 minutes after check-in.

Please wait for your name to be called.

A nurse will assess the urgency of your injury or illness and talk to you about the type of treatment you need.

Assessment

Within each priority category, we treat the most serious cases first.

Patients who arrive by ambulance are assessed in the same way as people who arrive unassisted.

A specialist nurse, called the triage nurse, will assess the urgency of your injury or illness.

AssessmentCategories

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-RaySeating 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

Deliver

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

Deliver

Toolkit

Deliver

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



Evaluating

Implementation

PrototypingUser

Interviews


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

Thank you.

DAY 2

A Better A&EService Design: Innovation for the employed

A project led by PearsonLloyd

26-27 October 2015Brussels

European Social FundESF project 4985

Vlaanderenis werk

Welcome!

RecapDiscover DevelopDefine Deliver


Evaluating

Implementation

User testing

PrototypingUser

Interviews


through

Character Mapping

Observing

Workshops

Staff interviews

Visualising

Deliver


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


1. Improved patients’ experiences of A&E?2. Reduced the amount of hostility, aggression and violence experienced by staff and patients?

Deliver


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

Deliver

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 theimproved signagereduced their frustration duringwaiting times.

of patients feltthe Guidance Solution clarifiedthe A&E process.

For every £1spent on the design solutions,£3 was generatedin benefits.

Patients’complaints relatingto information andcommunication felldramatically post-implementation.

Threatening body languageand aggressivebehaviour fellby 50% post-implementation.

Key findings show:

Deliver

88% 82% 78% 75%


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


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 collectionPr

e-im

plem

enta

tion

Sites Staff survey

Patient survey

Ethnographic observations

Post

-impl

emen

tatio

n

Pilot sites(Aug-Sept 2012)

Pilot sites(July 2013)

Sample size: 120 across both sites






yes

yes

yesno

yesno

Control sites(Sept & Dec 2012)

Control sites(July 2013)

Deliver

Cost : Benefit Ratio

For every £1 spent onthe design solutions

was generatedin 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 collectionAugust 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



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


Evaluating


Implementation

What next?

Next steps

1. Develop a master plan

Next steps

1. Develop a master plan 2. Get senior management to buy in

Next steps

1. Develop a master plan 2. Get senior management to buy in3. Engage the workforce

Next steps

1. Develop a master plan 2. Get senior management to buy in3. Engage the workforce 4. Review current situation

Next steps

1. Develop a master plan 2. Get senior management to buy in3. Engage the workforce 4. Review current situation5. 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

Addenbrooke’s Hospital, Cambridge

Newham Hospital, London

Norwich and Norfolk Hospital, Norwich

Royal London Hospital, London

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

Implementations

Whittington Hospital, London

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.

Ten key lessons...

1: Frontline research is crucial

2: Other industries can unlock new ideas

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

4: Manage expectations

5: Know how it will benefit you

6: Embrace the design process

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...

Risks

Risks, Challenges

Risks, Challenges, Successes...

Happy users

Better service

Benefitsstakeholders

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

www.ABetterAandE.com

Government & Nonprofit

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