NHS X GSA
Product Design Year 3 December 2015
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Introduction
This project is based in an open source environment where everyone has the ability to identify, raise and present solutions to improve determined issues or situations.
GSA x NHS is a collaborative project between third year Product Design students at the Glasgow School of Art and Crosshouse Hospital. As an Open Source project, our aim for the project was to develop a set of tools that requires the application of staff knowledge in order to identify challenges within the area of patient flow. For this project we worked in groups but collaborated all our findings so that our information was as accurate as possible. Within our studio environment we worked as a class with a flat hierarchy (no one had more power then anyone else) in order to share the workload and produce our deliverables.
Contributors During this project we worked with many hospital staff and the patients seeking care in order to get a range of perspectives. These included nurses, charge nurses, doctors, junior doctors, patients, bed managers, discharge co-ordinator, porters and domestics. The information we gathered from everyone we observed and interviewed contributed to the entire design process.
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Initial Analysis
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Methods Used
Week
Field Research
Discover & Define
Table of Contents 2
Process
Example
How It Works
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Final Product
47 Deliver
Traingle
Roleplay
Insight Cards
Identifying Opportunities
Mapping Data
Gathering Information
Area of Focus
13 Develop
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Discover & Define
1
Discover / define
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Develop
5 Deliver
Field Research Methods Used Initial Analysis
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Field Research We gathered basic information about each area so that we as a class could start to understand the patient flow process. For our first trip to the hospital we started by attending the morning huddle to see how information is shared after a shift change. We then separated into groups and each covered a different part of the hospital. The areas we went to during this visit were: A&E, cardiology, pharmacy, respiratory, gastroenterology and discharge. We gathered basic information about each area so that we as a class could start to understand the patient flow process.
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Methods Used During our research time at the hospital we used various methods to gather information. We choose to take a very personal approach therefore, spending little time looking at big statistics and more time on personal stories and observations.
Observations One of these methods was observation. We let staff go about their day as usual and we simply shadowed without interfering whist taking notes and sketching. This allowed us to gain a more accurate view of what staff do on a day to day basis and how they move around the hospital.
Interviews
We also conducted informal interviews with members of staff. The hospital was very busy so it was difficult at times to obtain the information we wanted but we were incredibly grateful for all the time people spared for us. We also interviewed patients so we could find out how they personally felt their time in hospital had been. This was very valuable to us as it gave us personal perspectives and also allowed us to compare different parts of the hospital.
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Initial Analysis Developing User Journeys After our first visit to the hospital, we began to sort through all the data we had collected. Each group began to build a user journey specific to the area of the hospital they had visited. This meant we could see an overall view of how parts of the hospital worked, who was involved at each stage of a patient’s journey and the feeling at each stage. These individual would later come together to provide a broad overview of most areas of the hospital. This would lead us to ask better, more informed questions on our second visit to the hospital.
1 Nurse has taken care of patient for a long time.
2 Nurse finishes her shift and goes home.
5 Nurse feels she hasn‘t finished providing the whole patient care ‘package‘.
4 Nurse returns and patient is gone without previous notification.
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3 Patient is discharged and goes home.
Each group began to build a user journey specific to the area of the hospital they had visited. This would lead us to ask better, more informed questions on our second visit to the hospital.
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Develop 1
2
Discover / define
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4
Develop
5 Deliver
Areas of Focus Gathering Information Mapping Data Identifying Opportunities Insight Cards Roleplay Triangle
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Areas of Focus After grouping the information, we came up with new titles for the areas we wanted to focus on during our second visit to the hospital and the rest of the project: A&E, discharge, patient role, pharmacy, communication and trust. We returned to the hospital to gather more in-depth information and ask specific questions for each of these areas. However, our main aim for our second visit was to get more of an idea about staff and patient feeling. This meant we conducted longer interviews to find out personal stories and the reasons behind them.
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TRUST
DISCHARGE
PATIENT ROLE
PHARMACY
COMMUNICATION
A&E
For the second vistit to the hospital, we conducted longer interviews to find out personal stories and the reasons behind them.
Gathering Information We then had a class workshop to map all of this and the previously gathered information in various user journey timelines. We realised each one is unique to the individual but we could group information to particular circumstances to understand the routes people take in the hospital and who is involved at each stage. These journeys could then be analysed to identify where patient flow lost efficiency. We used a process called affinitising which consists of correlating a large amount of information in order to find themes and patterns. This is usually done using headings and post it notes that can be rearranged as more information is added and changed.
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Mapping Data Pat
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Huddle D/C Office Enters Ward Converse at nurse station Compare notes Enquires about patients Look for doc for discharge Aftercare Requirements Doc confirms discharge Discharge Arrangement
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Having found themes and patterns from our collaborative research, our next steps involved visualising these insights in easy-to-understand infographics. The goal of these was to help us more easily digest the masses of data collected as well as help us realise new insights through our mapping.
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Cycle of Work
All the acquired information was used to create infographics so our research could be better understood by ourselves and in turn our client. 17
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S.S.A.
Discharge Info Updated
After Care Peace of Mind
Entry
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Physiologist
t nt Tes me t a Tre
Diagnosis
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Family
Nurse
S.S.A.
Recovery
HC
Family
Physiologist
Discharge
Physiologist
District Nurse
HC
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Doctor
Treatment
Patient Peace of Mind - Discharge
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relatives are worried, confused, stressed
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Recovery
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• waste of doctors time
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• relatives cannot help the patient
• doesn’t help the patient • waste of doctors time
• longer and bad recovery
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• passive patients • possible waste of time and beds
Discharge
no activity (unnecessary) waiting time bored, frustrated
• no timeplanning is communicated to patient
rd Wa d n o Sec
y
no understanding of diagnosis confusion, panic, stess
feeling uncomfortable cannot sleep, relax worried, anxious
Treatment
• no activity • unpleasant, noisy, busy, strange environment
• information is not well fitted to patient
people that don‘t need to go to the hospital
• waste of doctors time (and resources)
Diagnosis
• no additional info given to the family
• people are not aware of their health • not well educated
Entry
Patients Involvement
Reliability
* Data from NHS Report
Discharge Coordinator
Huddle Information
E-Whiteboard System
PMS System
Symphony System
Predictions E-Whiteboard
Bed Manager Report
12 am
3 am
Bed Manager shift begins 6 am
Information Reliability
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12 pm
Disch. Coord. Ward Rounds End
Peak Information Transfer
Morning Huddle
Disch. Coord. Ward Rounds End
3 pm
Night Bed Manager shift begins
Afternoon Huddle
6 pm
Disch. Coord. Shift Ends 9 pm
Perception of patient
Nurse
Discharge coordinator
Ward Whole hospital
The discharge co-ordinator and nurses have a different views about patient flow that bias their decisions. Nurses are focused on patient care in the ward whereas the discharge co-ordinator has an overall view of the hospital.
This is reflected in the difference in language used when speaking about patients; the discharge co-ordinator is more focused on patient flow and the nurses more on patient care.
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Lack of understamding of each others roles Patient
I feel better. I want to go home.
I know the patient very well. I don’t think he should go home yet!
Nurse
Doctor
This patients results are fine but the nurse doesn’t think he is ready to go home.
Understanding Lack of understanding of each others roles.
I need to free up beds and this patient can go home! His test results are fine!
Discharge coordinator
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Can anyone be discharged? Is the patient profile filled in?
Yes, but I need a consultant to sign the papers.
No, sorry. There‘s no time today.
No, what do you need to know? When can John X go home?
Is the E-Whiteboard up-to-date?
Once S.S.A. and homecare have had MDT meeting.
Discharge Coordinator: Interactions
80% simple
20% complex
discharges
Complex VS Simple Dicharges
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Trust in the system Discharge lounge
I’ll check the information just in case
Manual telephone
The patient is ready to go
There are many systems in the hospital for the transference of information between staff. Some communication systems don’t provide the right information at the right time due to staff not updating them or not following procedure. Some staff
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E-Whiteboard system update
Ward
members feel more confident about using over another. As a consequence, staff don’t always trust that the correct information is being shown. They use another system to double check the information which slows down the whole process.
Patient medication narrative
Admission check medical history
It is hard to remember everything!
Home
Ward
take medicine
medicine administered
How should I take the medicine?
Patient
What is this medicine for?
I feel overwhelmed. Too much information!
Discharge
explain home-care
This graph shows an example of a patient‘s journey from admission to home. It touches upon four areas: admission, being in the ward, discharge and, at home. It describes and addresses the patient‘s concerns regarding medication.
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Pharmacy
home care medicine administration
medical history
diagnosis & label understanding
patient awareness of medication
hostpital care
Patient Awarness All 4 touchpoints are about patient awareness but, at different Stages.
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medical history Pre Hospital
difficulties remembering medical history
patient awareness of medication During Hospital
Some patients do not know what they get some medicines and other medical treatments for
diagnosis & label understanding Every medicine has its own label with information on dosages and administritive guidlines which can make the patient confuesd Post Hospital
medicine administration
Problems
Patient gets confused by the complicated information they receive from doctor
Touchpoints of pharmacy
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The sandwich effect
Doctor
Nurse
Patient
Nurses can feel overwhelmed or ‘sandwiched’ as they have contact with both patients and higher management. Therefore they need to retain a lot of information and act like the middle man constantly transferring it. They serve as the face of the service to the patients.
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Staff interactions with patients
Bed manager discharge coordinator No time
Doctor Twice a day
Nurse Every two hours Patient
Nurses spend the most time with patients and may pick up on subtle behaviours. However they may become more attached to the patients which influences their decision making. The discharge coordinator sees an overview of the patient and so may not understand why this can affect the nurses’ choices. This contributes to the gap of communication between the staff.
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Auxiliary Nurse
Staff Nurse
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Communication Channels
Junior Doctor
Consultant
Symphony System
E-Whiteboard System
Desktop Computers
Laptop Computers
PMS System
Landline Telephone
Patient Profile
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Communication - Overview
Staff Access
Social Services
Meal Plans
Archived Patient Files
Online Booking System
Doctor Notes
discharges etc.)
Bed Situation (Free beds, query
Radiology Database
Blood Results
Test Results
Pharmacy
Discharge Transportation
Discharge Coordinator
Bed Manager &
Auxiliary Nurse
Departments & Information Accessible
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Observations
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Mis c. F orm s
Nurse Ward Round
Check Bloodwork
Request Archived Files
Reviews Patient File
Consultant-Nurse Review
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Arrival
Updates Notice Boards
Updates E-Whiteboard
Assessment by Nurse
Arrival in Ward
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Communication - Inpatient Cycle of Care
Ward Round
Homecare
Transport
Consultant
Medication
Critically-Led Discharge
Test Results & Diagnosis
Book Test
Update Consultant Notes & Files
Talk to Patient
Check Observation Clipboard Cycle of Care
Discharge
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Location
Ward 4F (intensive)
Who
Junior doctor
Surgery
Nurse
Senior doctor
Communication
Pager
Whiteboard info
Problems
Patients too ill to communicate
Other
Aware that hospital is outside peoples’ comfort zone
Aware of patient journey
Relatives involved in cares
Adopt certain posture, attitude when at work
Active staff support
Design Opportunities
Communication between relatives and nurses
Quotes
Aware that hospital is outside peoples’ comfort zone
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»I’ve got the feeling that I am not giving enough care to patient, but when I see feedback it is all about hospital, not nurses. I guess patients are happier than I imagine.«
Ward 4E (general)
Discharge lounge
Nurse
Bed manager
Relatives
Porter
Junior doctor
Senior doctor
Discharge coordinator
Lounge admin
Whiteboard info
Phone call informatic system
Discharge script Discharge booklet
Perception of care Whiteboard not often updated
Bed manager on top of the hospital organisation
Perception of job for nurses
Disagreement about complex patient discharge
Not always a doctor available to sign patient’s discharge
Basic feedback sheets given to patients
Trust
Discharges are customised
Communication nurses/discharge coordinator/bed manager
»When I have to discharge, nurses feel the whole package of care hasn’t been provided.«
No trust in the electronic system
Close environment, transition to go home
Discharge delay for patient’s comfort
»I always have to phone the ward to be sure electronic information is right and complete«
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Entry
Diagnosis
Treatment
Stress
Happiness
Understanding
Waiting
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Recovery
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Discharge
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s No idea how far along the process they are
Bored
Given too much info to digest
Unsure of what is next. How long to wait
atm Tre
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Tired Frustrated
Annoyed
Stressed Scared
Overwhelmed
Relieved
Stressed Scared
Patient feeling
Discharged
nd Ha
Hig
ep hd
Attended to by nurse throughout day
Nurse settles patient
Porter moves patient to a new ward
Admitted
Treatment or treatment plan
More depth tests & diagnosis
General tests & diagnosis
Describe issue
Backstage
Diagnosis
Family wastes Doc’s time with Q&A
Organise bed or discharge progress
Process results
Assigned priority
Receptionist puts in info (general, specific)
Patient view
Check in Treatment
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Staff collect meds from pharmacy
Secretary checks patients out
Jr. doc. prints off medication for pharmacy
Family – Doctor communication
Jr. doc. uploads info
Request for home-care written in file
Nurses fill out paperwork in corridors
Documentation of tasks with patients during day
Can patients do something more productive with time?
Bored
Doesn’t trust nurse to answer questions
Happy
Impatient Frustrated
Grateful Happy
Stressed Scared
Releived
nsp Tra
ort
Home
Picked up by family or friends, or hospital arranged transport
Waits to be picked up
Porter moves patient to discharge
Patient monitoring Nurse / Junior Doc. / Senior Doc.
Porter moves patient to a recovery ward
Middle grade or senior doctor ward round
Recovery Discharge
m Ho
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Identifying Opportunities
Interviews
Insights & Opportunities Mapping Journeys
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Observation
When it came to identifying opportunities, we wanted to make sure we had a range from all six groups. We therefore gathered five illustrated insights from each group and presented them to the class so that everyone was aware of all the findings. A group of people then returned to the hospital in order to check the accuracy of these insights from the areas they were gathered. As a lot of our insights were based on feelings within the hospital and between staff, it was difficult to decide whether they applied to many people or were very specific. Adjustments were then made according to the updated information that was brought back and from these, we were able to start developing our tools.
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Nurses are too busy caring for patients to fill out paperwork and update E-whiteboard. Leads to incomplete information.
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After we identified possible opportunities, a group of people returned to the hospital in order to check with the staff the accuracy of these insights from the areas they were gathered.
Lack of trust in the E-system leads to information being double checked.
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To display our insights in the clearest way possible, we choose to design a set a cards. They represent the main issues that each group identified during their research in the different areas of the Hospital. They represent not only problems, but also design opportunities to improve the patient flow in the hospital. Each contains a scenario of an issue and the respective personas that interact in that situation. They are organised in three different colours that represent three categories of issues: Red for patient issues Salmon for issues between staff and staff Blue for issues between staff and patients These insights work as a tool to help the hospital improve its communication flow, trust and accuracy.
Insight Cards
Each Insight Card contains a scenario of an issue and the respective personas that interact in that situation. 42
From our research we found that, at times, there seemed to be a lack of empathy and understanding between staff. In that sense,developed a role-play game that allows staff to address issues within the hospital by engaging with each other and talking them through. We developed scenarios based on our insights that can be acted out so that the issues. These are an alternative to the insight cards that allow staff to identify the issue and the root of these issues themselves. The process of the role-play is in the form of a booklet so that is easy to follow and understand. Our hope is that the essence of the role-play can be used in the wards to quickly put staff in others shoes to help the understanding of issues in different roles. The next tool we developed allows staff to design outcomes to solve issues identified in the roleplay.
Roleplay
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Triangle The Triangle of Communication is a tool that we developed to help the hospital staff to break down communication issues and find opportunities for design. It works as a complementary tool to the roleplaying game helping discussion among participants. The tool is made of a drawing of a triangle that represent three elements that ensure good communication: Understanding, Knowledge and Trust. Each vertex represents the maximum score of each element. Users can then evaluate each of the key aspects of communication after and give them a score from 1 (bad) to 10 (good) based
on the following questions: Knowledge: How accurate was the information? Understanding: How clearly was the information transmitted? Trust: How well did people rely on the information that was being passed? Once the users have given scores to each element, a new triangle is formed by joining the dots that reveals the areas where users can work on solutions.
Aim: Without good communication processes follow a different path than intended. Within communication there are three elements: Understanding, Trust, and Knowledge. This tool helps you identify which of these elements have room for development.
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How to Draw the Triangle? 1. To evaluate each element, ask yourself in a scale from 1 to 10:
3. Connect the dots with lines. UNDERSTANDING
A. Knowledge: How accurate was the information? B. Understanding: How clearly was the information transmitted? C. Trust: How well did people rely on the information that was being passed? 2. Draw dots in the lines with the values of each element.
KNOWLEDGE
TRUST
4. If the corners of your drawn triangle, are close to the center, then these are the elements that need improving.
UNDERSTANDING
UNDERSTANDING
KNOWLEDGE
TRUST
KNOWLEDGE
TRUST
5. Use the triangle to discuss where could communication be improved.
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DELIVER 1
Discover / define
2
3
4
Develop
5 Deliver
Final Product How it Works Example:
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Final Product The final product we have developed is a set of tools that should be used in conjunction with hospital staff. The insights we have gathered are only a starting point to build on and to help people see how they can think about other issues they themselves have identified within the hospital.
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EXAMPLE:
The triangle represents the best possible communication. All three elements got the highest score (10).
(1) Bad (10) Good The lines in the middle represent a scale from 1 - 10 for each elemtent, from bad (the centre) to good (the end of the lines). Scenario: Alex told his friend Sam to come to the party sometime in the evening. He expected Sam to arrive at 8 but Sam arrived two hours late. Discussion: — “I think Alex and Sam trust each other because they’re long-time colleagues... we can give Trust an 8” — “Their Understanding seemed to be quite good since they both knew there was a party. It’s a good 7” — “But Alex didn’t was a bit vague about time. He never told Sam the specific time. Let’s give Knowledge a 3. There is an issue here that we can work on”
The new triangle that you have drawn represents comminucation in the scenario.
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Create Your Own Although we carried out research in the hospital, we weren’t able to spend a lot of time there. We also went in a fairly personal direction and therefore, a lot of our insights are based on individuals’ opinions and stories. This means that other members of staff may want to note down their own experiences to discuss and these templates facilitate this. The research we conducted can be carried on, developed and added to by members of the hospital who have more in-depth knowledge of patient flow.
The ‘Identify scenarios’ booklet enables users to identify and record issues in the hospital environment. By doing this you create a platform where you can begin to understand an issue. We use this tool to understand different perspectives on the issue, understanding these different perspectives gives you a true representation of what is happening around the hospital.
After identifying issues, staff can then put their problems into blank versions of our outcomes. These allow staff to make their own insight cards and scenarios for role-play.
Building on the understanding of the issues using insight cards and the roleplay, you can begin to brainstorm ideas on how to provide a solution to the problem By asking “How can we?” or “How might we?” you can create a discussion around the issue and how you are able to solve it. Viewpoints from different professions provide an array of possible solutions.
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After five weeks of hard work, late nights, miscommunication and a whole heap of optimism, we have arrived with a combined outcome that we are all proud of. We have learnt a lot about field research and about service design but the thing we have struggled most with, and hence learnt the most about, is teamwork. It hasn’t been easy, but who said working with your 30 of your friends in a flat hierarchy would be? It has been a constant battle to design with a shared vision class vision and not just with a small committee. Sitting here and writing this in a studio that more resembles a war room then classroom, it’s amazing to think how motivated and hard working everyone is. We have truly come together as a year group to produce something we see as realistic and that we are proud of. We really hope that the tools we provide are of use to the staff of Crosshouse Hospital and will help them to better understand where, when and why problems with patient flow arise.
Conclusion
We would like to thank everyone who helped us during the project. We are extremely grateful to all the staff in the hospital who took time out of their busy schedules to help us with any questions we had. They provided us with crucial knowledge that made this job possible. Finally, we would like to thank Dr Hans Hartung and Karen Bell who facilitated this project and were our points of contact throughout the five weeks, always available and receptive to our queries and suggestions.
We are extremely grateful to all the staff in the hospital. They provided us with crucial knowledge that made this job possible.
We would also like to thank our tutors Stuart Bailey and Ian Grout as well as Jamie Sunderland who was our guest tutor during the project.
Thank You! 52
Team: Diane Arnold Graeme Bell Lena Clasing Mor Dagan Luis de Sousa Jana Dreyer Moritz Ebeling Luisa Felappi Imogen Foulkes Maximillian Hans Ashleigh Jamieson Anna Jannas Amalie Kvistgaard Laura MacDonald Ross McIntosh Lia Barahona Morales Alexander Nielsen Alexander O’Neill Charline Roussel Greg Smith Alexandra Steenbeek Kirsten Stewart Peter Swanton Santiago Taberna Satsuki Tanaka Braden Tinline Franziska Waldschmidt Mai Watanabe Fred Wordie Xuanyu Zhang
Contact: Stuart Bailey s.bailey@gsa.ac.uk
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NHS X GSA