It's not just about time! a fuelfor design exploration into the experience of waiting in healthcare

It’s not just about time!

A design exploration of the waiting experience in healthcare

Wait

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...it’s not just about time!

We all know how it feels to wait. Waiting is part of our everyday life; we wait for the bus, we wait for a friend to arrive, we wait our turn to be served in a shop. Sometimes we enjoy the wait, it gives us a chance to breathe and reflect. At other times it’s a disruption to our routine that leaves us frustrated, stressed or simply bored.

Waiting is a consistent pain point at different stages of a health care experience. We wait for a consultation or to obtain our test results. Waiting in a hospital or clinic can be especially difficult as we could be in pain, feeling anxious about our health condition, or confused by a procedure we do not understand. Waiting in healthcare is rarely positive.

Many health systems are working hard to reduce waiting times as a means to improve efficiency and perceived service quality. But as health services around the world are increasingly overstretched, waiting becomes an inevitable part of every healthcare journey. So how can we improve the quality of a waiting experience in healthcare?

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“The amount of time that patients spend waiting, and their discomfort in waiting long periods before being seen by a doctor, can significantly influence their satisfaction with and evaluation of the service.”

Source: ‘The waiting experience and consumer perception of service quality in outpatient clinics’ S.De Man, D.Vandaele, P.Gemmel, University of Ghent, February 2004 4

fuelfor decided in the summer of 2010 to explore the topic of waiting in relation to healthcare services. It’s a topic that varies with each medical service and situation. We therefore decided to focus on the patient experience in a clinical waiting room setting, taking a typical wait for a doctor consultation as a basic and familiar situation that could help reveal more generic insights and opportunities related to waiting in healthcare.

We wanted to understand through design research which specific factors create discomfort - physical and emotional - for people waiting for a medical consultation. We found that existing research into the psychology of waiting in queues provided some very relevant insights for the healthcare waiting room experience.

Secondary research findings were further validated and elaborated through a series of site visits to several clinical waiting rooms in Barcelona to observe people’s behaviours in context.

Additional interviews with service providers and a discussion group with patients who had experience of health systems in the US, Europe and Asia provided rich input to the design exploration.

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Our tolerance for waiting depends upon the perceived value of that for which we wait.

David H. Maister in his book ‘The Psychology of Waiting Lines’ identified three types of waiting: pre-process, inprocess and post-process. The pre-process wait occurs before a service starts (e.g. waiting to check in at a clinic reception). An in-process wait is during the service (e.g. waiting as a physical examination is performed) and a postprocess wait is after the service finishes (e.g. queuing to pay or complete paperwork for a consultation.) Pre-process waits are perceived as longer than in-process waits. Inprocess waits are the most tolerable and post-process waits the least tolerable. Applying these principles to a healthcare waiting room experience, it would be possible to improve the overall waiting experience by making the pre and post-process waiting time feel useful or valuable.

This feeling of neglect can be further amplified when the waiting environment itself (furniture, lighting, signage etc.) does not adequately support a sense of comfort and wellbeing. In addition, public waiting areas in healthcare are spaces where people who are unwell can feel exposed and vulnerable. No one likes to suffer in public.

The most profound source of anxiety in waiting is wondering how long the wait will be.

If a patient in a waiting room is told that the doctor will be delayed thirty minutes, he experiences an initial annoyance but then relaxes into an acceptance of the inevitability of the wait. However, if the patient is told the doctor will be free soon, he spends the whole time in a state of nervous anticipation, unable to settle down, afraid to depart and come back. This sense of being tied to the spot can create both physical as well as emotional discomfort. Moving around may reduce pain or provide distraction, and just having the option to do so may reduce anxiety.

People have a fear of ‘being forgotten’ by the service whilst waiting, but they may also wish they were ‘invisible’ to Waiting in ignorance creates a feeling those around them, so they can maintain of powerlessness. a sense of privacy in their sickness.

Waiting room layout can add to this sensation when there is a lack of line-of-sight between patients and staff.

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This frequently results in visible irritation and rudeness on the part of people as they harass staff in an attempt to reclaim their status and rights as ‘paying’ clients. A lack of effective information and communication around the waiting experience can lead to this type of discomfort.

Often it is concluded that extra time is required to communicate effectively with people, however it is not the quantity of time spent but rather the quality - format, mode, content - of the communication. In this way additional information can be provided without further demanding time from staff who are usually already overstretched.

When there is no visible order to the waiting line people remain in a state of nervousness about whether their priority in the line is preserved.

A fair wait feels shorter than an unfair wait. The etiquette of waiting varies greatly between cultures and across contexts within a given society; the nuances of how people cope with a waiting order must be taken into consideration for successful service design since it builds upon existing social norms and expectations.

It can also lower their expectation of a service ,and since a healthcare service is expected to care for you, this can lead to overall disappointment and frustration.

These characteristics drive people’s behaviour in healthcare waiting spaces - people act reserved, hide away, are indifferent to one another, get frustrated and find themselves lost. It became clear that by understanding these factors that drive discomfort, and therefore a more careful consideration of the design of the waiting area its layout, furniture, signage and services - a waiting room could potentially improve overall levels of satisfaction as well as the effectiveness of service delivery itself.

In short, if we feel taken care of, respected and informed we might be able to tolerate even long waits with greater comfort.

Check out our foundation research material through the Public Evernote link below: http://www.evernote.com/pub/lekshmy/waitingexperience

A healthcare waiting room is not a place people choose to spend their time.

A waiting room has a negative perception as a sterile and perhaps unhygienic place where germs and bugs abound.

This impression naturally leads to an underlying discomfort and sense of urgency to leave the space as soon as possible.

This impatience can impact people’s tolerance of service delays, errors and inefficiencies.

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Project process overview

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Insights Synthesising our data from secondary desk research and fieldwork observations and interviews with service users and healthcare providers, we defined a set of key insights that relate to the experience of waiting for a consultation in a healthcare setting.

Each insight into the current experience is described on a separate card, the title of each card opens up a particular opportunity area to improve the experience of waiting. A trigger for ideation of solutions.

The insights capture the physical, emotional and spatial aspects of the waiting experience.

By combining them and mapping them to time and the process of waiting provided a clear innovation framework for the project.

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Key stages of the waiting experience From arrival and registration at a clinic or hospital reception, all the way through to medical consultation and departure, the waiting experience is broken into key stages that impact the overall waiting experience. Consideration was given to people having to wait while their loved one consults the doctor.

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Each stage was colour coded to indicate the pace of activity at that point, a faster pace with a more intence colour. A time icon indicates the typical relative duration of each stage.

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Waiting room seating is functional and generic, forcing people to make work-arounds in order to create some personal space.

“I try to find a seat that is closest to my doctor’s door.”

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...It’s about seating that offers you choice in comfort.....

MODU is a modular furniture system that can be adapted to support different types of activities, people and facilities; elements can be reconfigured by a healthcare provider as a service evolves. Moveable arm rests and a choice of different density cushion pads allow people to create their own physical comfort zone. Wheelchair users and children in strollers have designated waiting space alongside their loved ones. Soft design qualities communicate comfort, but not at the expense of hygiene, with specialist material finishes ensuring safe surfaces. Active and passive air cleaning is achieved through integrated ventilation and carefully chosen plants. A queue management system provides displays at each end of the seating unit, reassuringly near to people as they wait.

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18 I Moveable armrests allow people to configure the exact seating space they might need

An integrated play zone for children. I 19

20 I Seating options for wheelchair access and families with strollers.

Acoustic separators for making a private phone call. I 21

...It’s about seating that caters for people.....

When you sit at a table its surface naturally creates a personal space around you.

TABLEAU is a communal table for waiting rooms that provides social and private space for people to read, write, relax or socialise.

Integrated lighting, storage and queue management displays create a dedicated area in which people can prepare or debrief after a consultation. Service staff can also use the table as an informal work space or a place for conversations with patients and loved ones.

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24 I Flowers that clean the air, whilst overwriting that typical hospital smell.

Prepare and Remember cards are available at the table for people to make notes before and after a consultation. I 25

Queue management displays in waiting rooms make people feel physically tied to one spot.

The only relevant patient information on this ticket is an anonymous number. Its disposable quality mismatches the importance of the service to patients.

...It’s about a sense of freedom whilst waiting.....

INLINE is an iPhone application that tells you more than just your number in the queue. You can use it to make your healthcare appointment, locate your doctor’s consultation room at the clinic, as well as make use of your waiting time for a better, more effective medical consultation. Features include reassuring dynamic updates of your position in the queue, a place to keep health notes, medication records and access to information about local activities for a healthier lifestyle. Simple visual interfaces make waiting time, effective time for you.

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30 I An iPhone application that brings together relevant health information for your consultation.

A pre-triage feature can help people prepare the information they need to share with their doctor. I 31

32 I After a consultation people can receive clear, understandable and trackable information about their medications.

Location markers en route support people in finding the quickest way to an appointment. I 33

Test results, referral papers or administration slips are all props that support service providers in delivering care.

How can people understand what is happening to them during an appointment?

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...It’s about tools that help people utilise waiting time.....

FOLIO is a low-tech solution that helps people review and organise their medical consultation records, past and present. Important details about medications and appointments are stored in a simple paper wallet. Prepare and Remember cards on which people can record their personal health notes can be kept safely in one place, ready to bring to a consultation. Information is deliberately simple, visual and color-coded for easier interaction.

Individual healthcare providers can always tailor the content and branding to reflect their own health care services.

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38 I Each pack supports one consultation with clear reminders of the time, date and location of an appointment.

Tear-off strips provide pharmacists with essential information whilst ensuring people can keep hold of instructions. I 39

40 I A map helps people locate their waiting room at the hospital or clinic.

Simple questions and diagrams prompt people to capture the essential information to be shared with their doctor. I 41

Multiple public health messages in waiting rooms create visual noise that numbs the target audience into ignorance.

The ubiquitous vending machine offers unhealthy snacks that contradict public health messages.

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...It’s about positive health messages that trigger our curiosity.....

COUNTER ACT is a freestanding vending unit for the waiting room that combines a display surface for public health messages with the vending of healthy snacks and water. More kitchen counter than vending machine, the unit triggers people to interact and practice healthy habits in a context where they are likely to be thinking about their health.

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46 I Placing a cup on the sensor plate automatically dispenses a portion of your recommended daily intake.

Choose from a single fruit serving or a pack of the typical five-a-day recommendation. I 47

Magazines are often the only kind of entertainment or distraction offered to people in healthcare waiting rooms.

Waiting room environments tend to be souless spaces with sterile, cold qualities that remind us of illness rather than wellness.

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...It’s about a waiting room that makes you feel healthier.....

HEALTHPOINT is an interior architecture concept that is designed to promote healthy living, whatever your health condition or lifestage.

A welcome wall as you enter introduces the doctor’s on duty for consultation as well as a variety of local healthy activities. At the rear of the space is a workshop area that can be used by local health and social care services for group meetings, classes etc..

Local citizens can share their healthy tips and stories to create a living library of community health to inspire and encourage active lifestyles.

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52 I A flexible workshop space to host a changing agenda of health-related meetings, events and classes

Leaflets sharing local citizen’s health stories and tips help to create a health conscious community I 53

54 I The INLINE application reflects the local healthy activities advertised in the waiting space.

A leaflet with information about local healthy activities can also be inserted into the consultation FOLIO I 55

MODU sound barrier

priority seat badges

adjustable arm rests

flower bed

card & pencil holder

wait queue display

appointment menu

location sensitivity

active navigation

consultation folder

healthy activities flyer

medication support

selection interface

payment interface

health messaging

local health activities

card holder

screen displays

TABLEAU

INLINE

FOLIO

COUNTER ACT

HEALTHPOINT 56

blackboard kids zone

magazine storage

reading light

magazine storage

wait queue display

air-cleaning plants

wait queue display

cushions

active air-cleaning

pre-triage

consultation recording

health activities menu

health tips

medication support

lifestyle advice

health story cards

consultation map

visualised information

water fountain tray

cup dispenser

consultation room signage

local health activities map

card holder

trash & storage

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Project team: Laszlo Herczeg, Liliana Salazar, Ferran Lajara, Lars Stalling, Lekshmy Parameswaran, Peter Gal, Olli Niemi Special thanks to Dr. Ken Gorfinkle, Cristina Guembe, Marion Govert, Jan Henriksen, Marco Di Gregorio, Maria Santolaria, Gary Cook, Peter Drennan, Arun Herczeg

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About fuelfor Fuelfor is an innovation design consultancy specialized in health care. Founded in June 2008, the company is based in Barcelona and works with a team of world-class professionals to deliver integrated innovation services to global clients in the private and public sectors.

With over a decade of industry experience, fuelfor’s professional competences span from collaborative research and innovation design to product identity and implementation. They have worked across a spectrum of care contexts including oncology, labour and delivery care as well as chronic disease management and healthcare IT. Leading multi-disciplinary innovation design teams to deliver awardwinning health care products, services and strategies for clients in USA, Europe and Asia.

Fuelfor takes a 360° view that gives clients new ways to think about health. With a strong belief that research-driven design and multi-disciplinary collaboration are essential for innovation, they empower clients to see sustainable growth opportunities with greater clarity, and respond with viable solutions and strategies that improve the way people experience health.

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www.fuelfor.net, contact@fuelfor.net, +34 67 22 52 681, C. Zamora 46-48, 08005 Barcelona, Spain Š2011 fuelfor

a fuelfor publication Š 2011