Specialist Clinics Wayfinding Standards Final Report - Project Review

Department of Human Services 13 August 2008

This document is not to be copied without permission Growth Solutions Group Strategy & Marketing Introduction and Contents

Contents Page

Executive Summary 3

Chapter 1 Recommendations 4 Recommendations summary 5 Wayfinding recommendations 6 Setting expectations of a visit 7 This document provides a project overview, research findings Core wayfinding principles 8 and recommendations identified by Growth Solutions Group Use of the word ‘outpatients’ 9 (GSG) for design standards to create consistent and patient- Hierarchy of information 10 friendly wayfinding and signage across Victorian Hospital Appointment letter 11 Outpatient Departments. Key signage content 12 Implementation 14 The Specialist Clinics Wayfinding Guidelines is presented in Taking a whole-of-hospital approach 15 conjunction with this report, in the form of an outpatients- only wayfinding design guidelines manual, for distribution to Chapter 2 Findings 16 hospitals for implementation. Outpatient visits 17 Patient journey 18 Patient interview findings 19 Staff interview findings 23 Site visit findings 26

Chapter 3 Project Overview 28 Context and aims 29 Project Scope, issues and timing 30 Timeframe 31 Site visits and interviews completed 32

2 Executive summary

Based on the positive potential impact on outpatient experience, DHS should implement a generic ‘address paradigm’ wayfinding system for outpatients across Victorian public hospitals, as detailed in the accompanying Specialist Clinics Wayfinding Guidelines document. Further work should be done to extend these principles to the entire hospital and all patients, visitors and users.

• GSG was engaged by the Outpatients Reform Team, DHS, to develop signage design standards and a Specialist Clinics Wayfinding Guidelines document which will equip hospitals to improve their outpatient wayfinding and experience, plus explore a new name and identity for Outpatient Departments.

• GSG worked to a four month project timeframe between April-July 2008. Key activities and deliverables included visits to four reference hospitals and interviews with patients, staff and the Outpatient Experience Sub-Committee.

• The key findings were that:

- Outpatient visits make up a large proportion of total visits to hospitals and outpatient clinics are key destinations.

- Although each patient is different, the outpatient experience follows a predictable process with opportunities for setting expectations and improving the patient’s experience.

- The complexity of many hospital sites, combined with the locations of clinics and the varied mobility and cognitive needs of many patients gives rise to a need for improving patient wayfinding.

- The term ‘outpatients’ does not hold relevant meaning for patients.

• In summary, the recommendations, which form the basis of the Specialist Clinics Wayfinding Guidelines document (presented as a separate document) are:

- To improve patients’ ability to find their way to an outpatient clinic, a generic and standardised information system should be introduced that treats destinations as ‘addresses’.

- The ‘wayfinding’ communication should be separated from the ‘expectations-setting’ communication and the medical explanations.

- Create a wayfinding system that is generic, universal and internally consistent between verbal, written and signage communications

- De-emphasise (or remove) the word ‘outpatient’ and use generic destination markers for wayfinding.

• It became clear during the project that a whole-of-hospital wayfinding solution is now needed that builds on the outpatient wayfinding work but considers the full range of visitors and relationship between different services and parts of the hospital.

3 Chapter 1 - Recommendations

4 Recommendations summary

By applying a set of patient oriented wayfinding principles to an outpatients journey, Victorian hospitals can improve the experience of patients visiting outpatient clinics. The Specialist Clinics Wayfinding Guidelines document that accompanies this report can be used to implement best practice principles across the state, however DHS needs to consider how a whole-of-hospital system can be developed.

Recommendations on the wayfinding solution: • These recommendations form the basis of the • To improve patients’ ability to find their way to an Specialist Clinics Wayfinding Guidelines document outpatient clinic, a generic and standardised developed by GSG. information system should be introduced that treats destinations as ‘addresses’. Further work: • The ‘wayfinding’ communication should be separated • The wayfinding solution for outpatient visits raises from the ‘expectations-setting’ communication and questions about how it links in with other hospital the medical explanations. journeys. • Create a wayfinding system that is generic, universal • In order to provide a wayfinding solutions that and internally consistent between verbal, written and works for outpatients but is also integrated and signage communications consistent with the rest of the hospital, a • De-emphasise (or remove) the word ‘outpatient’ and wayfinding solution needs to be developed for use generic destination markers for wayfinding. whole-of-hospital planning.

5 Wayfinding recommendations

To improve patients’ ability to find their way to an outpatient clinic, a generic and standardised information system should be introduced that treats destinations as ‘addresses’. Further, other communication methods should be used to help set patients expectations of their visit.

Where do I go for my appointment? We recommend (and when?) • Wayfinding should use a • This is a standard wayfinding question - it is generic and standardised like asking for an address ‘address’ paradigm designed exclusively for getting first- • DHS should create a standard system for time visitors to specific key describing key hospital destinations destinations within a hospital Critical • Words used in the wayfinding patient system should therefore be questions generic and well-understood by the general (uninformed) public (reducing the use of complex What should I expect, and what is medical words for wayfinding expected of me? purposes) • This is a separate communication, including • ‘Expectation-setting’ verbal instructions from a GP, phone information should be instructions, an appointment letter, a leaflet, separated from signage and waiting room video screens, verbal communicated through other instructions from clerical staff means, but is an important part of the patient journey

6 Setting expectations of a visit

Patient experience can be improved by designing information and communications that set expectations of an outpatient visit - reducing confusion and helping patients plan appropriately for the experience.

Patient question Content of answer Method of communication

Where do I go? Standard wayfinding instructions In an appointment letter, use of [warn of distance if will be an issue] screens, moving words On signage, e.g. 500m from car park When do I go there? Clear date and time In an appointment letter How long will it take? Estimated duration range In an appointment letter Verbal updates at clinic reception Possibly on signage What preparation do I need? No need to fast (no anesthetic will be In an appointment letter administered) What do I need to bring? X-rays, appointment card, medicare card... In an appointment letter What is the purpose of the What I’m being treated for GP or specialist verbal advice visit? What stage this is In an appointment letter The type of visit, e.g. consultation with a doctor for diagnostic purpose Note that no surgery or procedure will be done on the day How much will it cost? Public hospital - no charge Verbal on request What can I expect the next Typical process of diagnosis, treatment Specialist verbal advice in at a stage will be? plan, treatment, follow-up consultation Who will see me? An individual doctor’s name if possible, or Specialist or GP verbal advice the nature of the specialist 7 Core wayfinding principles

Hospital signage and wayfinding systems should be designed to make it easy for first time visitors. Where journeys are complex, they should be broken up into stages through navigation to key hubs / destinations.

The wayfinding system needs to be Design principles within hospitals designed with these principles in mind: 1. Use landmarks, architectural features and 1. Design for the people who have the most central ‘hubs’ within hospitals as key difficulty finding their way (i.e. the elderly, navigation points those with limited English, vision impairment 2. Break up complex journeys by directing or mobility problems) patients first to key navigation points, then 2. Reduce complexity and remove any words or supply secondary navigation information to symbols that are unnecessary or do not find a more detailed location (start broad, contribute to patient understanding then zoom in) 3. Ensure absolute internal consistency (i.e. 3. Not all destinations in a hospital need to have words and symbols always mean the same signage - there is a hierarchy of information thing within a single hospital system) based on total visitor numbers - label the destinations that account for 80% of visits 4. Aim for as much external consistency as possible* (i.e. consistent systems across all 4. At each journey decision point, list hospitals in Victoria) - a patient may visit destinations that ‘break off’ from the main many different hospitals over time path, and signal “All other places” to reduce the need to list every other destination

* Note: although it is useful for the wayfinding system to be universal across all hospitals, unlike the Emergency Department signage system, it is not necessary for there to be a universally recognisable visual ‘brand’ for outpatient departments across different hospitals.

8 Use of the word ‘outpatient’

We recommend, from a patient point of view, the word ‘outpatient’ is not used as a primary navigation word within the wayfinding system.

Naming principles: destinations within hospitals should be named for the patient who is uninformed or has a low level of English. That means generic labels (e.g. floor numbers) and reduced use of medical terminology.

Why should the word ‘outpatients’ be dropped from main wayfinding?

It is not necessary, and confusing, It is not understood by Its meaning varies across for wayfinding purposes patients, and is a misleading hospitals, and is changing over • A patient only needs to know how to label time get to a destination within the • Patients interviewed either • An outpatient visit is often not hospital report not understanding the made to an outpatient • ‘Outpatients’ is seldom a single word, or incorrectly define it department destination (e.g. it is often on • Patients’ mental framework for • Increasingly, outpatient visits multiple floors, or in different parts an outpatient visit is “going to may occur in surgical wards, day of a hospital - at least 6 different see a doctor at the hospital” procedure centres, or other clinic areas in the Royal Melbourne • The label ‘outpatient’ is negative spaces in the hospital - it is no Hospital) in that it labels the patient, rather longer one contiguous place than the treatment or service • There is no single definition of ‘outpatient’ • Peter MacCallum Cancer Centre now calls them “Specialist Clinics”

Note: we would also remove the misleading term ‘ambulatory care’, which is poorly understood by the general public Trends in patient-sensitive labels should follow the trend to name someone as “a person with a disability” rather than a “disabled person”

9 Hierarchy of information

Finding a destination involves a hierarchy of information starting from the macro and moving to the micro.

Wayfinding instructions should only include a direction where there are multiple choices at a decision point in the journey. Information should be revealed in a hierarchical ‘need to know’ order as people only remember the last couple of instructions in a journey.

Use the minimum amount simple site may only need 2 of information and reveal key pieces of wayfinding on a ‘need to know’ basis information

A complex hospital site A simple hospital site

Hospital / Health Service Austin Health Traralgon Hospital

Site Heidelberg Repatriation Hospital single site

Entrance X street entrance one main site entrance

Parking place Front car park one central car park

Building / entrance Tobruk Building main entry one obvious main entrance

Level Ground floor easy to signpost the location of clinic from main entrance

Hub destination Clinic B Clinic B

10 Appointment letter

The appointment letter or card needs to follow the wayfinding structure that appears in signage.

Dear Mrs Malthus-Johannsen,

Your doctor has referred you to see a specialist at Austin Hospital. Here are the details of your appointment. (call 555-5555 if this time or date does not suit you)

Wayfinding When? 24 March, 2008 at 1pm Duration: Allow 2 hours for the wait + appointment

Where do I go?

Austin Hospital in Heidelberg Central tower Level 3, Clinic B Hospital Building Destination

Suggested travel: By car - enter from Tomas St, park on level 3 By public transport - get to Heidelberg Station, follow signs to main entrance Expectations- What do I bring? Medicare card, something to read during the wait (if you wish) setting How do I prepare? No preparation needed. There will be no surgery done on the day. Visit type You are in an Orthopaedic Clinic (fixing bones and joints)

11 Key signage content

The key to simplifying a complex journey is to break the hospital down into key ‘destination’ hubs that can be well sign-posted, with secondary destinations indicated once the hub is reached.

At the hospital entrances

Reception A 4-6 major internal destinations are identified and highlighted at entrances Reception B Use generic, well-understood labels for these hubs Clinic C Focus on the key areas patients need to self- Wards 1-3 navigate to - other areas will usually require directions from a hub

Radiology (x-ray, MRI) Major secondary destinations visually Cafe take a secondary place at entrances Pharmacy Testing

Note: these are Illustrations only. Refer to Specialist Clinics Wayfinding Guidelines for sign recommendations

12 Key signage content - hubs / key destinations

Signage should clearly label key destinations / hubs, set expectations on arrival and enable navigation to secondary destinations.

At the key destination entrances At the exit to a clinic

Reception A Way out Priority goes to likely Specialist Clinics (outpatients) destinations after a Radiology (x-ray, MRI) visit to a clinic Pathology (blood tests) Eye Clinic [or Clinic A1] Pharmacy (medicines) Cafe Ear Clinic

Reception A Other key destinations are Reception B second at this point Clinic C What do I do? Wards 1-3 See the clerk Wait until called (waits can last 1-2 hours at busy times) Ask if you have a question Note: these are Illustrations only. Refer to Specialist Clinics Wayfinding Guidelines for sign recommendations

13 Implementation - managing hospital differences

The wayfinding principles and standards will need to be applied at different levels depending on the complexity of the site and the extend of legacy spaces and signage investment.

Simple site (existing) Complex site (existing) Greenfields site • Wayfinding may be relatively • Each site will need its own • Recommendations should form straightforward given few choices analysis and individual part of the architectural and wayfinding recommendations - wayfinding brief • Analysis by the hospital may the exact same solution will not indicate navigation and wayfinding is • Universal addressing system can apply to all sites not negatively impacting patient be implemented across letters experience • The addressing system can be and signage implemented across appointment • Hubs can be created and links letters between hubs made explicit • Most existing signage may stay in through architectural features place, with key ‘hubs’ identified • Non-medical parts of the hospital and highlighted on signage can be used as hubs, e.g. cafes, • Hubs can be selected based on entrance lobbies, etc. volume of foot traffic and architectural features that facilitate navigation • Signs may be replaced in a hierarchy: • Key entrance points • Arrival at the clinics • Journey across the hospital

14 Taking a whole-of-hospital approach

There are some points for consideration by DHS before launching the Specialist Clinics Wayfinding Guidelines to hospitals for implementation.

• The scope of this project was limited to outpatients and the recommendations do not provide an end-to-end hospital solution for wayfinding, including signage, and patient experience. However, it is impossible to isolate the complete outpatients journey from other parts of the hospital.

• A wayfinding system that is implemented only for outpatient visits would be a second-best solution if it is different to the wayfinding in the rest of the hospital. In some cases, this could even increase confusion if a hospital simply added outpatient signs that are different to legacy systems.

• It has become clear during this project that a solution and guidelines documentation is needed that addresses the whole hospital and carefully considers the full range of visitors and relationship between different services and parts of the hospital. Further work needs to be done, leveraging and extending the wayfinding principles developed in this project.

15 Chapter 2 - Research Findings

16 Findings - Outpatient visits are a major source of hospital ‘traffic’

Outpatient visits make up a large proportion of total visits to hospitals, and outpatient clinics are key destinations within hospitals.

Outpatient visits, Victoria 2000-2007

2.0M

1.5M

1.0M

Estimated outpatient visits as a % of total 0.5M patient visits - examples 75% - Peter MacCallum Cancer Centre 40-50% - Ballarat Base 0M Hospital 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 50% - Austin Hospital

Source: GSG hospital staff interviews Source: Your Hospitals Report 2006-07

17 Findings - Patient journey

Although each patient is different, the outpatient experience follows a predictable process with opportunities for setting expectations and improving patient experience.

Patient Stage What patients need to know Process opportunity for communication GP referral Why? Role in my treatment GP contacts outpatients centre, data entered, triaged by registrar in clinic [urgent 1-2 weeks, 30, 90, 365 days]

Notification of How it works, why, how long likely, Allocated for referral; Letter generated and sent referral next step

Appointment When, where, why, Letter generated and sent; call made if within 1 week of letter from hospital expectations referral

Physical journey Patient arranging for transport, assistance, interpreter, time How do I get there? What’s expected? to the clinic off work, etc.

Arrival & wait When will I be called? What can I do Clerk takes time of arrival and details while I am waiting?

Appointment Medical instructions, actions Name called in waiting room; taken to consulting room; may be baseline observations; sees specialist

Follow-up What should I do next? Next a) reviewed appointment b) discharged Source: GSG outpatient staff interviews c) tests: radiology, pathology, ECG, pharmacy, etc. 18 Findings from patient research - summary

Findings from the patient interviews are: • Outpatient visits constitute a large proportion of total patient visits to hospitals. • The complexity of many hospital sites, combined with the locations of clinics and the varied mobility and cognitive needs of many patients gives rise to a need for improving patient wayfinding. • Although each patient is different, the outpatient experience follows a predictable process with opportunities for setting expectations and improving patient experience. • Patients are frustrated mainly with the wait and uncertainty over it, and generally don’t rate wayfinding as a major problem despite many first-time patients requiring assistance to find their way to their clinic. • Regular patients often have reconciled themselves to the wait frustrations, and find the term ‘outpatients’ does not hold relevant meaning for them.

19 Source: Outpatient interviews at outpatient departments of Royal Victorian Eye and Ear Hospital (15 May 08), Austin Hospital and Heidelberg Repatriation Hospital (22 May 08) Findings from patient research

Patients are frustrated mainly with the wait and uncertainty over it, and most first-time patients required assistance to find their way to their clinic due to the complexity of the journey.

Methodology: private interviews with a total of 27 patients waiting for appointments in selected outpatient clinics: Austin Hospital and surgical clinics, Heidelberg Repatriation Hospital vascular and orthopaedic clinics, Royal Victorian Eye & Ear Hospital general eye clinic. Patients interviewed included 15 (with guardian) to 80 year olds, mix of mobility issues, 3 people with interpreters, most were not first-time visitors. Patients were asked about their journey to the clinic that day, as well as recollections of their first visit, frustrations with the journey and experience in general.

Finding Comments

The number one frustration is the “The doctors are never on time” length of wait and lack of “My appointment time was 10:15am and the clinic only opened at 10am. Why am I still waiting [at communication around the wait time 11:30am]? How many people do they double book?” “Surely there is a better system”, “it basically takes half a day” “Last time I was here, my appointment was at 2pm and I got out of here at 6pm” Many first time visitors to an “I had to ask at the reception desk” outpatient clinic could not find their way unaided “The first time we asked at the main reception where to go, then we realised it was really easy” “I wasn’t too worried [about finding where to go]. I had to bring my husband here before” “It’s impossible to find the main entrance from outside the hospital [by train]. We need more signs”

Car parking - finding the right one, Finding the car park can be difficult - “the instructions in the letter didn’t match what the signs said” cost, complex journey - is identified as a key frustration Car parking carries a cost - “It’s gotten more expensive” Car park space availability - “going around and around the car park [is frustrating]” Difficult not knowing how long the car park is required Many frustrations relate to the design Issues such as not seeing the same doctor twice, patient histories being misplaced, desire to do tests of the process in their local area and not at hospital, and the high number of review vs. new patients are structural issues that need their own separate consideration in order to improve patient experience.

20 Source: Outpatient interviews at outpatient departments of Royal Victorian Eye and Ear Hospital (15 May 08), Austin Hospital and Heidelberg Repatriation Hospital (22 May 08) Findings from patient research .../2

Patients want their hospital visit to be as smooth as possible, and feedback and communication are key tools to achieve an improved experience.

Finding Comments

Patients want to have an experience that They want - is as smooth and pleasant as possible Staff to be helpful and be patient To go to the right place (and ideally have all parts of their visit on one floor or location) To reduce the amount they wait, and at least know how long to wait. For there to be a ‘nice’ environment, e.g. with TV and a place for children. New patients are often anxious, and a A good system provides feedback to the user on where they are in the system - creating a confusing system or unclear process greater sense of control over their destiny. Low knowledge leads to higher anxiety - about increases that anxiety where to go, how long to wait, what is expected. New patients are often confused about Patients ask - what am I coming there for? Confused over seeing a doctor. why they are there Some patients expect to have procedures done and fast before a visit unnecessarily. Lack of information and expectation- “Nothing is said about what’s going on” setting lead to frustrations “Do I have time to go to the cafe?” Perceptions that the doctors don’t get here on time and stand around chatting with others “Staff have no idea of the time... I ask, ‘is that hospital time?’” “It’s a communication thing” Repat system of calling people at their appointed time reassures they are in the queue and helps set expectations about wait times (given the number of people with the same appointment time who queue up)

21 Source: Outpatient interviews at outpatient departments of Royal Victorian Eye and Ear Hospital (15 May 08), Austin Hospital and Heidelberg Repatriation Hospital (22 May 08) Findings from patient research .../3

Regular patients often have reconciled themselves to the frustrations of waiting, and find the term ‘outpatients’ does not hold relevant meaning for them.

Finding Comments

‘Outpatients’ has little relevance and “Doesn’t mean much” meaning to new patients or their carers “I don’t really get it” “Means absolutely nothing to me” “Initially I didn’t understand [what outpatients meant]. Now I look at it basically like a number” Definitions of ‘outpatients’ vary, but “You were in and now you’re out, you’re no longer in the hospital” regular users simply see it as meaning “Clinics and after care” they are not an inpatient “Before admissions, or not being admitted” “I’m a patient, but I’m not an Inpatient” “Not in a bed. Being treated and you’re living at home” Many people (particularly repeat patients) “It’s only the waiting [that’s frustrating]. But that’s OK, I’ve got no where else to be” are accepting of the frustrations “I don’t mind waiting, but the process can be frustrating. The staff are doing a fine job. I feel for them” “I’m just resigned to being patient. I just need to know where I’m going ” “It’s good because it’s a free service, therefore I put up with the inconvenience” Frustrations and dissatisfaction are often Language barriers meant individuals often arrived with a support person related to the personal difficulties or The medical experience can affect perceptions of the outpatient clinic - adjacent patients may seriousness of the medical situation have very different medical experiences (we noted minor surgery next to oncology clinics) One patient with mental disability couldn’t sit in crowded part of waiting room Many patients with low mobility need lifts or Red Cross transport “I get stiff if I sit here too long”

22 Source: Outpatient interviews at outpatient departments of Royal Victorian Eye and Ear Hospital (15 May 08), Austin Hospital and Heidelberg Repatriation Hospital (22 May 08) Findings from outpatient department research

The findings from interviews with staff from outpatient departments and from the Outpatient Reference Committee are outlined in this appendix.

Finding Comments

Visits to specialist outpatient clinics are Peter MacCallum Cancer Centre - 73% of all visits are outpatient the majority of hospital visits, but Austin Hospital- 50% of all visits hospitals are not usually designed with this in mind Sites visited so far have outpatient clinics placed far from the main entrance

Trends are toward ‘outpatient’ treatment Long term decline in number of people staying overnight and length of stay and away from inpatient treatment Increasing numbers of new patients referred to outpatient clinics - e.g. The Alfred had 4,310 new outpatients in 3 months of Apr-Jun 2007 up 46% from 2,961 in Oct-Dec 2004* Care is moving away from a visit to an Diagnosis or treatment may occur as part of ward work, in a specialist clinic or a general outpatient department as a single outpatient clinic experience Surgical clinics cover diagnosis and treatment (e.g. application of a plaster, wound care) in one space In some large US hospitals, care is often organised by condition type, with outpatient, treatment, tests and surgery all in one area. Definition of outpatients is not clear within “Outpatients is anyone who is not an Inpatient” - yet this definition is not accurate in the way it hospitals and for the general public is applied “Outpatients is a word we understanding within hospitals, but I don’t think the public understands it - the are just ‘going to the hospital’” Definitions used for non admitted patients are not uniform and have varied over time between States and Territories

23 Source: Outpatient Experience Sub-Committee and reference hospital staff interviews Findings from outpatient department research .../2

Finding Comments

The outpatient journey may often involve A typical new patient may need a consultation with a doctor, then a visit to diagnostic services visits to several different parts of the e.g. Pathology and Radiology, which may be on the campus but operating under separate hospital brands A consultation may include a minor procedure, or a referral to another space for a procedure to be conducted Post consultation can include a visit to pharmacy

Clinics are often on multiple floors Austin Hospital, Ballarat Base Hospital, , Royal Victorian Eye and Ear Hospital all have three or more different outpatient spaces Heidelberg Repatriation Hospital has a single outpatient building which facilitates navigation, although new visitors find it hard to know which site entrance to use and where to park given the size of the site and number of different buildings Not all clinics have the same design / Surgical review clinics are best served by a large open space where the doctor can quickly layout needs review large numbers, rather than individual consultation rooms

There can be large differences in patient Children can be waiting in the same waiting room with people who have serious medical type in one space conditions, despite having very different needs Some patients are new (and may not know the system), and others may be regular visitors Some sites have challenging physical The Austin Health brand operates across three key sites: there is more than 1km from properties to contend with Heidelberg Repatriation Hospital to the main Austin Hospital property Equipment requirements may dictate spaces: e.g. inability to move MRI machines

24 Source: Outpatient Experience Sub-Committee and reference hospital staff interviews Findings from outpatient department research .../3

Finding Comments

Hospitals would be interested in wayfinding “specifics around ideal outpatients facility for greenfield sites” guidelines and principles rather than a “don’t be prescriptive, focus on principles” narrow set of rules with forced compliance Guidelines will have to encompass the range of differences in scale and complexity across different hospitals, including - dealing with multiple sites - realities of legacy buildings and architecture - complexity of site - existing signage, design, colours and location Hospitals are likely to be protective of local “The rules relating to Emergency signage were good, but the implementation company often independence / need for local flexibility applied them in an inflexible way”

There may be challenges implementing a Outpatient Experience Sub-Committee members tend to have a broader view and are keen to ‘universalist’ model for outpatient see a universal and common wayfinding system not only within hospitals but across all wayfinding hospitals

25 Source: Outpatient Experience Sub-Committee and reference hospital staff interviews Site Visit Findings

Austin Hospital and Heidelberg Repatriation Hospital Ballarat Base Hospital

• Three campuses with same brand in different location • Outpatients operates over three different levels for • Two key campuses are 1km apart specialised clinics Patients are required to walk and take elevators between • People often go to wrong campus – 1st letter to • key spaces Outpatient containing appointment information is critical • Providing maps doesn’t always help navigation • Inconsistency in naming convention of buildings, eg. building names versus level numbers and directions: • Austin Hospital is a complex site North/West etc) • multiple entrances to site • Upon leaving the Outpatient area, patients may have to • sloping site – ground floor entry at different points is find their way to six key areas – Carpark, Radiology, MRI, across multiple levels Pathology, ECG or Pharmacy • campus has 2 hospital brands in one building – Austin • MRI and Radiology are at opposite sides of the building Hospital and Mercy Hospital for Women • Patients are seen by multiple specialists in one location • 30+ multiple level buildings, not in ordered layout for surgery and pre-op • Outpatients journey to key spaces requires them to move • Patients sometimes have special needs eg. sight or across multiple dimensions; up levels and across hearing impairment, mobility issues, need for an buildings that are not in a straight line interpreter. This is often flagged before patient arrives, but not always • Heidelberg Repatriation Hospital site is large • With the current set up, children and people with serious • Outpatients must walk long distance from car park and to medical conditions can be waiting in the same waiting other hospital areas. Important to park in the right car room, despite having very different needs park zone • Surgery patients may need to go to Outpatients then pre- • Acknowledged lack of adequate way-finding tools in place admission in a ward, all in one day

26 Source: reference hospital site visits and staff interviews - Ballarat Base Hospital, Austin Hospital and Heidelberg Repatriation Hospital, Royal Victorian Eye and Ear Hospital and Site Visit Findings .../2

Box Hill Hospital Royal Victorian Eye & Ear Hospital

• Box Hill is not a particularly complex site for Outpatients: • Access is an issue given parking restrictions and the fact - central main building, spanning multiple levels that the site is on Victoria Parade Additional complexity due to 2 buildings which are - Outpatients Department located on the ground floor • connected at more than one level through complex close to the main entrance (approx 50m) corridors - Outpatients is a clear destination, but there are numerous other clinics in other parts of the hospital • Navigation within each building is relatively easy due to (over multiple levels) and other smaller buildings relatively small building footprint and multiple levels: patients can easily navigate to the right level using the • The major concern of staff is that the site was not lifts originally designed to be a major hospital dealing with At each floor, an obvious reception area draws visitors high volumes of people. Today the infrastructure is • to the appropriate place stretched to the limit: - the hospital main entrance is relatively small and the • Outpatient clinics exist on multiple floors, so it is key to drop off zone banks up regularly know the right clinic, which can be confusing High contrast and appropriate text size is critical for this the Outpatients area is also too small and, particularly • - hospital given some vision impairment of patients - at peak times, is overcrowded and noisy current signage size and contrast is often insufficient - back office staff in Outpatients find the environment disruptive and stressful. Some barriers are required • Coloured lifts concepts is not always clear to patients Vast majority of visits are outpatient visits: • The key issues specific to way-finding and signage are: • - The main directory board lists every destination, uses - it is the critical wayfinding issue for the hospital long medical terms and is too cluttered to be useful (surgery patients appear at a single pre-admission clinic on ground floor) - No clear signage to direct people to Outpatients reception hub - Lack of clear lines of sight

27 Source: reference hospital site visits and staff interviews - Ballarat Base Hospital, Austin Hospital and Heidelberg Repatriation Hospital, Royal Victorian Eye and Ear Hospital and Box Hill Hospital Chapter 3 - Project Overview

28 Context & Aims of Signage Program

As part of a range of DHS initiatives to improve patient services outcomes, a new set of signage standards is proposed to be developed and implemented across Outpatient Departments throughout Victoria.

Context • The Outpatient Improvement & Innovation Strategy (OIIS) is reviewing a range of initiatives to improve patient services in outpatient departments across Victorian public hospitals. Aim of signage development project • As part of these initiatives, improved wayfinding and signage has been raised as a priority. • The aim of this program is to develop a recommended wayfinding and signage guide • An audit in 2007 has identified inconsistent and sub-standard document, for health services to use when signage. Research indicates patients are confused about what to do, updating or making improvements to their where to go and what happens next inside outpatient departments. departments and to develop a new name and visual identity for Outpatients Departments • There is no existing central quality control or set of standards for across Victoria. outpatient signage. • Hospital conditions and patient information needs (e.g. different cultures and languages) vary across the state. • The 2007 review identified system-wide as well as site-specific issues which will be considered as part of the project.

29 Project Scope, Issues & Timing

The project sought to develop signage design standards and a Specialist Clinics Wayfinding Guidelines document which will equip hospitals to improve their outpatient wayfinding and experience, plus explore a new name/identity for outpatients.

Pilot Project: Central Question Scoping In the context of other Outpatient Department improvement The following areas are within scope : graphic design initiatives, what signage design standards should DHS set to of: improve patient experience, and how should it rename the • External signage on outpatient department Outpatient Department for improved public understanding? • Signage inside outpatient department • Key wayfinding points to destinations outside the Related Issues to consider department, but that form key parts of a typical outpatient experience • What core signage requirements do departments have? • What are the patient information needs and what role can signage play in meeting those needs? Naming, consumer focus groups and stakeholder consultation • What combination of colour, typography, iconography, graphics assist wayfinding and emotional reassurance? • What name should be used to label the Outpatients Department Out of scope: Site-specific recommendations or any that improves understanding? implementation of signage (technical spec, costings, production, installation) • How do outpatient departments connect to other parts of the hospital to create a seamless patient journey? • What signs must be universal across all ED’s, and what secondary Note: the recommendations will be based on visiting signs can vary depending on local needs? four sites, and will only cover wayfinding issues that are raised on those four sites as representatives of all sites; What rules and processes can be put in place to ensure • issues unique to other sites would require separate consistency and improve central control of signage? analysis and are out of scope • What non-signage communications should be considered (e.g. printed communications, digital screens)

30 Project Timeframe

GSG devised the following approach to the project, which involved three key workstream phases.

April May June July Activity 14 21 28 5 12 19 26 2 9 16 23 30 7 14 21 28 Week commencing

Project Reviews

Phase 1 - Signage needs and Information design Review research reports Site visits Customer research Design brief

Phase 2 - Signage Design Concepts

Phase 3 - Final Recommendations Syndication

31 ✓

Site Visits & Interviews completed

GSG has completed the following patient and staff interviews, site visits and presentations throughout May and June 2008.

Outpatient Experience Sub- Hospital Site Visits and Staff Interviews 27 Patient Interviews SignageCommittee needs & information design Ballarat Base Hospital - 1 May Royal Victorian Eye & Ear ✓ Janine Harris - Director Outpatients ✓ Royal Melbourne Hospital • - 15 May ✓ • Marilyn Hitchock - Outpatients Clerk / Austin Hospital & Heidelberg Repatriation Administrator ✓ Hospital - 6 May • Belinda Rickard - Improvement Leader, ✓ Austin Hospital - 22 May Outpatients Department Peter MacCallum Cancer • Melinda Cosgriff - Business Manager for ✓ Centre Outpatients • Fran Brockhus - • Kim Hider - Consumer Participation Ambulatory Manager Project ✓ Heidelberg Repatriation • Megan Gray - Manager, Capital Works and Hospital - 22 May Infrastructure Outpatient Experience • Rhyl Gould - Director of Cancer and Spinal ✓ Sub-Committee Outpatient Services • Frank McNeil - Consumer ✓ Royal Victorian Eye & Ear - 13 May Representative • Stephen Vale - Executive Director Ambulatory Services • Robert Bak - Clerical Team Leader Presentations Eastern Health ✓ • Gary Grossbard - Head of Box Hill Hospital - 14 May ✓ Orthopaedics Box Hill • Mari Wintle - Nurse Unit Manager, Outpatient Experience Hospital Outpatients Department ✓ Sub-Committee - 17 June • Maria Tucker - Program Manager Emergency, Ambulatory and Allied Health • Sheryl Clark - Activity Clerical Supervisor