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News archive - January 2014

Reducing the impact of A&E

Reducing the impact of A&E

Hospital accident and emergency departments up and down the country are being urged to implement a new two-stage design intervention in a bid to improve the patient experience and cut down on violence and aggression against staff.

The Design Council and Frontier Economics have published evidence that significant improvements could be made by implementing a new, proven design solution created by PearsonLloyd.

Based on this evidence, the Design Council recommends that trusts adopt a solution known as ‘A Better A&E’. This incorporates a Guidance Solution - signage to guide and reassure patients; and a ‘People Solution’ - a programme to support staff in their interactions with frustrated, aggressive and sometimes violent patients through communications training and reflective practices.

The guidance states: “Patients in A&E are often in pain, with accompanying visitors worried about their condition. This pain and worry can alter the behaviour of patients and visitors, perhaps reducing their tolerance levels and making them more likely to behave aggressively.

“Improvements in the patient experience will not only reduce tensions and non-physical hostility, but prevent the potential escalation into more serious incidents, as aggression is often the consequence of accumulated frustrations. Our solutions focused on how the patient experience could be improved to create a calmer and more relaxing care environment for everyone.”

Guiding the way

The Guidance Solution is designed to be implemented in any A&E department and communicates basic information to patients, such as where they are, what happens next and why they are waiting. The information panels are implemented throughout the department and can work on their own or as a series. They are customised to each trust and illustrate the patient journey through the department.

The signs are supplemented by patient leaflets, with trusts currently helping to develop additional web and app-based delivery systems.

The People Solution involves two separate approaches. The first is for current staff and is a reflective programme challenging staff to consider, without blame, those factors that undermine their capacity to care for patients. The goal is to identify things that impact the collective mood and to work to remove the root causes and to prevent them from occurring in the future.

The guidance includes an ‘incident tally chart, which can be used during the programme to help focus on different variables within the system that might hinder the ability of staff to deliver high-quality care. The programme findings are reported back to management, helping the department as a whole to understand, learn and improve ways of delivering care.

This is supplemented by an induction pack for staff new to A&E to inform them of issues they may encounter while working in the department. This ensures that staff, such as trainee nurses and junior medics, have the required knowledge to work in this highly-pressured environment.

This new design approach has been brought together as part of an online document that offers free high-level design recommendations focused on the built environment and service changes. It is aimed at NHS managers, clinicians and healthcare planners who want to develop and deliver a better service in effective and inspiring environments.

The toolkit breaks the patient journey down into its different stages of the A&E process and presents case studies of best practice that are in place at NHS trusts across the country. It is intended to be used by all NHS staff, while also providing a reference source for architects or interior designers working on new-build projects.

Tried and tested

The solutions were first implemented at two pilot trusts - St George’s Healthcare NHS Trust in London and University Hospital Southampton NHS Foundation Trust (UHS). The implementation has been rigorously evaluated over the last year, and the key findings show:

  • 88% of patients said the new signage clarified the A&E process
  • 75% of patients said the new signage made the wait less frustrating
  • Threatening body language and aggressive behaviour has been halved
  • Offensive language and swearing has reduced by 23%
  • For every £1 spent on the design solutions, £3 was generated in benefits

‘A Better A&E’ was originally commissioned after it was discovered that one in 10 NHS staff members experiences violence at the hands of patients or their relatives every year. This is particularly prevalent in A&E departments and costs the service an estimated £69m a year due to high staff turnover, absenteeism and the need to employ specialist security.

The design team, led by Pearson Lloyd, was commissioned by the Design Council and Department of Health in 2011 to look at how design could create a better A&E by reducing the anxiety and frustration which often leads to violence.

‘A Better A&E’ is proven to be straightforward and readily implementable and can be tailored and retrofitted to any A&E department at a relatively low cost. The impact results are a conservative estimate and a more extensive study would capture the wider benefits of these design solutions, such as operational efficiency gains, that were outside the scope of the study.

Currently, the guidance has been rolled out at five trusts around England, including Newham University Hospital and Norfolk and Norwich University Hospital. It has also garnered interest from many others, leading PearsonLloyd to establish a stand-alone programme structure to help implement the solution at a national level.

Mat Hunter, chief design officer at the Design Council, said: “We are delighted that yet another collaboration between designers and the NHS has resulted in an ingenious and effective solution. This evidence proves that thinking and acting differently delivers more for less in public services. This solution must be adopted within A&E departments and adapted to support other healthcare settings. We must also replicate this creative approach beyond healthcare and there is no reason why it could not be used wherever poor customer experience leads to hostility towards staff."

Tom Lloyd of PearsonLloyd added: “Rather than tackling the rare cases of physical violence against staff, the team chose to tackle the much more prevalent and often more damaging culture of low level aggression targeted at staff. Research suggested that this damaging culture of interaction between staff and patients was often stimulated simply by patients’ lack of knowledge and understanding of how the system works, and what is likely to happen to them when in that system. Thus, improving people’s experience of services helps to make them less violent or aggressive.”

And Frances Wiseman, divisional director of operations at University Hospital Southampton NHS Foundation Trust, said taking part in the pilot had been a learning curve, adding: “Being involved in this project has been a catalyst for further work on staff engagement and empowerment within the trust. Certain aspects of the project have already become ingrained in the department, such as the guidance panels - it goes without saying that we will put them in our new paediatrics area.”

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