EMPATHYPATH Re-Envisioning Navigation Design for Complex Service Environments
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Mike Begley
EmpathyPath Re-envisioning Navigation Design for Complex Service Environments
Published by
211 South Broad Street. 5th Floor Philadelphia, PA 19102 Copyright@2016
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Empathy Path Re-envisioning Navigation Design for Complex Service Environments By Mike Begley
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree Master of Design for Social Impact in the College of Arts, Media, and Design The University of the Arts Philadelphia, Pennsylvania May, 2016
Approved by:
This book is dedicated to my late uncle, Richard Begley.
I would like to extend my sincere gratitude and devotion to everyone who has supported me along my journey as a graduate student. Thank you to everyone who has provided with guidance, support, and inspiration. Without you, this work would have not been possible. Lisa and Michael Begley Denise and Greg Deck Matt Van Der Tuyn Liana Dragoman Sherry Lefevre Anthony Guido Jonas Milder Jeremy Beaudry Jessica Tindall Michelle Sparrow ACC Check-in Staff Participating Patients ...my friends and wonderful family.
Table of Contents Project Introduction Meet Bob ............................................................................................................... 17 Marilyn Naimen’s Story .................................................................................. 19 Patient Centered Care is Important .......................................................20
Focus Study Observations What is a Complex Service Environment? .........................................24 Complexity of Hospitals ............................................................................... 25 Perelman Center for Advanced Medicine ........................................... 26 Abramson Cancer Center ...................................................................... 26 Building Schematic – Horizontal ........................................................ 28 Building Schematic – Vertical..............................................................30 Stakeholders................................................................................................. 32
Problem Space Consequences of Lost Patients ............................................................36 Competition in Health Care ....................................................................38 Bottom Line: Patronage and Referrals ........................................ 40 Bottom Line: Hospital Scores and Funding................................43 Bottom Line: Employee Satisfaction............................................ 44 Helath Care Space Difficult to Solve For ......................................... 46 Outpatient Space Even More Difficult to Solve For .................... 48 Wayfinding’s Roll in the Hospital Space ..............................................50 Traditional Methods and the Conventional Mode........................... 52 Time for Change...............................................................................................54 Problem Statement......................................................................................... 57
Intervention Opportunity Moving from Conventional Mode to Design Mode........................ 60 Applications of Design Thinking ..........................................................62 Applications of Design Thinking ..........................................................62 Benefits of Design Thinking ...................................................................65 Human-Centered Design and the Walking Interview ..................66 What Insights Does Human Center-Design Uncover ...................68 Wayfinding Elements and the Walking Interview ........................ 70 Designing for Sustainability ....................................................................71 Human-Centered Design Framework.................................................73 Empathy Path Design Framework & Thesis Statement ....... 74-75
Project Concept & Process Pilot Launch ........................................................................................................ 79 The Step-by-Step Process of the Walking Interview ....................80 Tools and Techniques.................................................................................... 82 Pitfalls and ‘Click-Points’ .............................................................................. 83 Capturing Information...................................................................................84 Participant Interviews...........................................................................86-104 The Questionnaire Booklet ....................................................................... 108 Booklet Results ........................................................................................ 110-119 The Questionnaire Booklet Closing Key Insights .......................... 120 Cross Pollinating Data ............................................................................ 122
Future Considerations Thesis and Pilot Recap ................................................................................ 126 Presenting Findings to the Abramson Cancer Center.................128 Actionable Steps (Check-in Desk and Landmarks) ..............130-131 Embedding Learning Systems in to Services...................................132 Road Coat Opportunity ...............................................................................135 Closing Statement ..........................................................................................137
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Project Abstract
Hospitals are complex service environments which require heavy cognitive burdens for ill, mentally stressed patients to navigate. Hospital layouts, especially within the ambulatory healthcare space, undergo ongoing waves of expansion and renovation, creating additional wayfinding nightmares for visiting patients and their families. Due to the necessity of rapid expansion and ongoing spatial renovations, traditional wayfinding solutions are falling short in providing effective and sustainable installations. EmpathyPath will exercise human-centered design research methods. The process will first capture navigational experiences of the ambulatory patient in the health care facility as they occur in real time, while accurately accruing rich data touch-points. Furthermore, EmpathyPath will identify effective and sustainable wayfinding solutions which will accommodate the constantly evolving hospital space. This project also intends to re-imagine how creatives can develop navigational design for non-health care service environments with human-centered solutions.
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Project Introduction Patients who face the reality of being diagnosed with cancer suffer from emotional and cognitive burdens of living with their illness. Routine activities such as commuting, finding a parking space, operating an elevator panel, and navigating a building can feel like insurmountable undertakings. Patients and their caretakers, including close friends and family, strive mightily to cope with the uncertainties of cancer diagnosis and treatment, while exerting tremendous amounts of emotional, physical and cognitive energy. On its surface, a trip to an outpatient hospital may bring to mind a simple, run-of-the-mill task. However, for cancer patients, the task is more than just an errand, but a much greater proposition. The doctor-visit experience is especially stressful when compounded by spatial complexities of hospital environments. For new patients, navigating unfamiliar, bustling treatment centers is a major hurdle. As a result, patients and care-taking family members become lost, frustrated, and dejected by clinical environments. Health providers are starting to take note of navigational problems with the on-set of patient centered care, where the act of finding one’s way through a hospital space is now regarded as a significant touch-point of the patient experience.
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Meet Bob Meet Bob, a sixty-eight year old resident from Lancaster County, Pennsylvania. He has just arrived at the Perelman Center for Advanced Medicine (PCAM), a multiuse outpatient health care facility. He is accompanied by his daughter Julia, who has taken the day off to escort him to his first appointment with a cancer specialist. Bob has recently been diagnosed with lung cancer. Bob and his daughter have traveled 50-plus miles on the Pennsylvania Turnpike. During their morning commute they hit traffic and are now running late for their appointment. Having finally arrived at PCAM, they now face a pressing issue in the health care domain, which is successfully navigating an unfamiliar complex service environment – resulting in a wayfinding nightmare. For Bob, the patient, and his daughter Julia, the care-taking family member, the complete journey from their home to a health care facility is a daunting experience. Not only did Bob and Julia travel a long distance to PCAM, find parking, and identify egress points into the building, inside they must orient themselves in a bustling, alien environment. They rely on a boundless amount of navigational cues to reach their specialist on time. In complex environments such as ambulatory hospital spaces, diverse patient demographics have different cognitive impairments and physical needs. In most sensitive cases such as Bob’s, frustration navigating an unfamiliar health care facility is compounded by the fear and anxiety of fighting a life-threatening illness. For Bob, making it to his appointment on time feels like a tremendous undertaking.
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Julia, the care-taking family member, is fighting the mental crisis of potentially losing her loved one. Just like her father, Julia may find the journey through a maze like health care facility – with its complex routes, turns, and corridors – to be stressful and intensifying to her own internal battles. Bob and Julia’s journey ends with one goal in mind. That goal is to finally meet with their specialist to receive potentially life-altering information. As they are now footsteps away from visiting the specialist, they face the hurdle of navigating the unfamiliar facility. Their daunting journey is filled with navigational directories that use strange, clinical nomenclature. Frustrated by the fact of already being late, Bob and Julia feel a sense of helplessness and loss of control in something as basic as making it from point A to point B.
Julia, Bob’s daughter, has taken the day off from her busy work schedule to drive her ill father to Philadelphia. As a caretaker, it can be difficult for her to maintain her composure, confidence and hope in front of her father. Julia’s experience represents the roller-coaster ride that many family members go through when their loved one is recently diagnosed with cancer.
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Marilyn Naimen’s Story Bob’s story is not uncommon for wayfinding cancer patients at the Perelman Center for Advanced Medicine (PCAM). In a February, 2014 Wall Street Journal article, Marilyn Naimen describes a similar story. Like Bob, Marilyn regularly commuted from the suburbs and described the difficulty of finding her way around the building. Marilyn, who was diagnosed with melanoma in 2009, said she received excellent care from the cancer center at PCAM. However, Marilyn’s testimony indicated the directional signage at PCAM was poor and proper information resources were difficult to locate. “To be sick and dealing with cancer issues in a building that is not user friendly is your worst nightmare” said Naimen. Once figuring out how to navigate the facility after a number of visits, Marilyn took the initiative to guide other PCAM patients who appeared to be ‘lost, scared, and frustrated’ (Landro, 2014).
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Patient Centered Care is Important, and Hospitals and Health Care Facilities are Taking Note Experiences like Bob and Marilyn’s are causing hospitals to realize the patient experience transcends the delivery of clinical care. Today, new policies and approaches are changing the branding of health care delivery. Among them, patient centered care (PCC) is a growing health care movement that prioritizes the entire patient experience. PCC values the consideration of integrated touch-points, while caring, respecting and focusing on patient and supporting family members needs and values. Health care providers are beginning to realize their environments should increase comfort and reduce anxiety to improve consumer satisfaction. Today, health care facilities no-longer want to be stamped as a place solely concerned about clinical care, but one that is empathetic towards the entire patient experience. Hence, hospitals and health care facilities are placing importance on promoting a perception that their facility is a ‘wellness promoting’ one and not just a ‘curing machine’ (Locatelli, 2015). Bob and Marilyn’s journeys navigating health care spaces underscore a very important non-clinical component in PCC – modern hospital architecture is a design problem as new visitors struggle to navigate it’s maze-like layouts. As hospitals expand and grow larger, the spaces become harder to navigate with success and confidence (Bunemann, 2012).
Marilyn’s Naiman’s story was featured in a Wall Street Journal article titled “A Cure for Hospital Design”, by Laura Landro. Landro identifies the scope and severity of lost patients in the health care space, while pointing to various wayfinding solutions being performed in hospitals across the country. Naiman’s story has prompted the University of Pennsylvania’s Health Care System to take note of patient wayfinding experiences.
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Health care facilities like PCAM have spent money and resources to make wayfinding – the act in which people orient themselves in physical spaces and navigate from place to place – a more intuitive and effortless task for patients. Kevin Mahoney, chief administrative officer at the University of Pennsylvania Health System, describes that “wayfinding is a challenge we have not yet 100% solved and we continue to work on it”. Since the publication of the 2014 Wall Street Journal publication, PCAM added two-patient information desks and digital kiosks. Additionally, the hospital has added three full-time greeters on each level of the parking garage to assist visitors like Bob and Marilyn the moment they arrive at the health care facility (Landro, 2014). Health care providers are realizing patients and care-taking family members are already burdened – mentally and physically – by fear of health uncertainties (Bunemann, 2012). There is a contemporary consensus among hospital planners to steer away from master plans that incorporate complex layouts, as they can intensify patient anxiety during navigation (Landro, 2014). Culminated by medical uncertainties, patients with cognitive limitations have severe difficulty navigating complex layouts that would be challenging for an otherwise healthy visitor (Bunemann, 2012). In extreme cases, patients who successfully find their destination, such as a waiting room, will be reluctant to leave their space in fear that they will not be able to find their way back to the room. (Carlson, 2010). As part of PCC, health care providers realize such navigational touch-points are major non-clinical issues that must be addressed.
Kevin Mahoney is the executive vice president at the University of Pennsylvania Health System. Kevin believes spatial environments of hospital buildings such as the Perelman Center for Advanced Medicine should allow patients and visitors to navigate its spaces with ease and confidence. Hospital administrators acknowledge spatial interactions can make the patient feel like they are in good hands, while representing their institution in a good, positive light.
Wayfinding is a challenge we have not yet 100% solved and we continue to work on it. – Kevin Mahoney, President of the Penn Medicine Health System
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Focus Study Observations Complex service environments are bustling, multi-operational facilities which provide varied services for multiple stakeholder groups. Since delivery of services mutate over periods of time, complex service environments frequently undergo structural renovations and operational transformations. The multifaceted service model, when compounded by layers of structural changes, make complex service environments especially difficult to navigate. The Perelman Center for Advanced Medicine (PCAM), a University of Pennsylvania Health System outpatient hospital facility, demonstrates navigation issues that patients face within complex service environments. PCAM is a multi-operational health care facility that packs in over thirty departments in a 500,000 square foot space. The architectural intricacy and ongoing structural renovations make navigation a common burden for its visitors. Navigational pitfalls occur regularly at PCAM, causing a substantial ripple effect on patients, health care providers, staff and executives.
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What is a Complex Service Environment? A complex service environment can be defined as a place, usually consisting of many different and connected parts, where a broad range of activities are delivered by a diverse set of providers. Complex service environments serve diverse consumer bases. Customers within the complex service environment, in comparison traditional consumer settings, are made up of diverse demographics with diverse needs. In this setting, customer experience is non-linear and consists of multiple touch-points. Examples of complex service environments include outpatient hospitals, transportation hubs, government buildings, and university campuses. The primary commonality of these locations are the diverse services they provide. Outpatient hospitals are complex because they offer different treatment services for sick, critically sick, and healthy patients. Outpatient hospitals, as well as inpatient, cater to the needs of care-taking family members. Meanwhile, transportation hubs demonstrate multi-faceted modes of transit such as trains, buses, shuttles, and airline connections. Government buildings house dissimilar, specialized departments such as a police outpost, a parks and recreation office, etc. University campuses are unique in that environment is not composed of a singular structure, but composed of many fragmented buildings that are connected by plazas, pathways and other interior connectors.
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Complexity of Hospitals Hospitals are complex facilities that are programmed to provide treatment for patients with various types of illness, stages of illness, while also providing routine check-ups for healthy patrons. It is ironic hospitals are places where people go to get healthy and where others go to stay healthy; hospitals are where mother’s go give birth and where the critically ill go at end of life. Caring for these diverse demographics are expert practitioners who work with specialized technology and start-of-the-art equipment. Over the past century, hospitals have enhanced treatment methods, while increasing their geographic footprint to accommodate the frenetic growth of the services they provide. Arguably, hospitals are the most complex of service environments, as expanding technologies and treatment methods are exponentially diversified on an annual basis.
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Perelman Center for Advanced Medicine The Perelman Center for Advanced Medicine (PCAM) is a 500,000 square foot outpatient hospital facility located in Philadelphia, Pennsylvania. Designed by world renowned architect Rafael Viñoly, PCAM opened its’ doors to patients in 2008. PCAM is comprised of over thirty departments and serves over 2,500 Rafael Viñoly is an award winning architect who was put in charge of the master plan of the $302-million project that is the Perelman Center for Advanced Medicine. Viñoly’s blueprint incorporated a central glass atrium at the core of the building, with three pavilions situated to the east, south, and west.
patients a day. Patient visits range from appointments for the oncology treatment to outpatient surgery. Since 2008, the building continues ongoing renovation and expansion to accommodate a high-density patient demographic, diverse work force of specialized doctors, nurses, and staff. Many patients and providers refer to PCAM as ‘its own little city’.
Abramson Cancer Center The Abramson Cancer Center (ACC) is regarded as one of the top-ten oncology treatment centers in the nation, practicing innovative ways to detect, diagnose and treat cancer. Residing in the west pavilion, the ACC is situated on the highest volume floor, which receives the highest patient population out of all the departments, and treats over two-hundred cancer patients a day. Since cancer patients are often compromised by heavy cognitive and physical burdens from their disease, ACC patients are one of the most susceptible patient demographics that struggle navigating their way through PCAM.
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PCAM Horizontal Schematic The horizontal schematic of the building is centralized around the center glass atrium that connects three outer pavilions to the east, south, and west. Patients enter the building primarily through the main atrium, which connects them to the outer three atriums where their final destinations and departments live. Nearly thirty departments are spread across PCAM’s three pavilions in sporadic order. Additionally, horizontal schematics alternate on each building level, making navigational wayfinding different from floor to floor. The master plan of the building was to facilitate three primary departments that would be situated in its own pavilion. But due to unforeseen changes, the emergence of additional departments forced the layout to become more sporadic from its original, intuitive design plan.
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Floor Plan Abstract
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STREET ENTRANCE & VALET SERVICE
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PCAM Vertical Schematic Since not every floor is the same in the Perelman Center for Advanced Medicine, there are many inconsistencies in the vertical arrangement of the building. Some floors do not afford patient accessibility by elevator. Dead-ends are created due to the structural architecture of the building. Additionally patchwork barriers were raised to accommodate the privacy of new patient populations. Vertical self-alignment and navigation can be a daunting task at the Perelman Center for Advanced Medicine. This is especially problematic when patients enter through the ground level lobby or one of the three parking levels. If the patient is navigating towards one of the three outer pavilions, they must take multiple elevators to reach their final destination. Additional maneuvering and vertical self-realignment adds confusion and frustration to PCAM visitors.
The left image demonstrates the building’s accessibility limitations. The core atrium elevators do not stop at the third floor. Therefore, visitors are required to take detours and an additional elevator rides to reach their desired destination.
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Elevator Accessibility
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Elevator accessibility in PCAM comes limitations and ‘none-connection’ points. These dead ends are especially frustrating for first time visitors who are utilizing the main atrium elevators. Additionally, ground connections to the west pavilion are blocked-off due to patient privacy concerns for the radiology demographic.
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Perelman Center for Advanced Medicine Stakeholders Patients and care-taking family members are at the forefront of importance in any stakeholder map. However, it is important to recognize the diversity of health care providers in the outpatient hospital setting. PCAM is the home of a laundry-list of specialized departments and clinical offices. Under each specialized department are teams of doctors, nurses, and supporting staff. Each department is backed by a team of clinical coordinators who optimize operations at PCAM. Each department operates under its own conditions, yet share spaces with other clinical departments in PCAM. For example Neuro-Oncology and Dermatology may redirect their patients to Cancer Nutrition Counseling. To keep patient reception fluid, clinical coordinators work with other departments to keep PCAM running at a high level. Coordination of many moving people, compounded by ongoing structural changes is a critical issue in a health care complex service environment.
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UPHS Administrators
Board Members
Departments & Services
Clinical Coordinators
Clinical Departments
Doctors
Nurses / Staff
Patients and Caregivers
Patient
Caregiver
Gastrointestinal Oncology Genito-Urinary Oncology Head & Neck Oncology Hematology Oncology Center Lung Cancer Melanoma Neuro-Oncology Cancer Nutrition Counseling Psychosocial Cancer & Support Rena Rowan Breast Center Lung Center Radiation Oncology Pre Admission Testing Proton Therapy Center Infusion/Photopheresis Pediatric Diagnostic Services Heart and Vascular Center Gastroenterology Dermatology SurgiCentre Urology Plastic Surgery Metabolic Bariatric Surgery Radiology Breast Imaging Rheumatology Infectious Diseases Internal Medicine Medical Genetics Memory Center Ophthalmology Endocrinology
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Problem Space State-of-the-art hospitals provide world class health care for its patients. But like many other complex service environments, hospitals are falling short in guaranteeing its visitors easy, intuitive navigational experiences through their facilities. It is well documented first-time patients have difficulty navigating complex hospital corridors, while comprehending notoriously complicated signage. Out of desperation, lost patients routinely resort to asking hospital staff, nurses, and doctors for directions. Frequent interruptions for directiongiving are costly and time-consuming, and are otherwise avoidable if intuitive navigation systems are in place. The consequences of lost patients are quite severe and can have an impactful effect on a hospital’s reputation and bottom line. Wayfinding firms, creators of navigational systems, strive mightily in creating intuitive solutions for lost patients. However, conventional wayfinding methodologies are falling short in keeping up with the frenetic, on-going changes that occur in health care complex service environments.
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Consequences of Lost Patients and Poor Navigational Experiences Patients visiting a hospital space for the first time are most susceptible to the panic of wayfinding in an unfamiliar space (Carpman, 2002). For visitors who have never been in a hospital or have had health care issues before, health care facilities are an intimidating, foreign complex service environment in comparison to a bank or grocery store. A lack of experience in a complex, high-tech medical environment, especially while facing the uncertainties of illness, can lead to great disorientation, confusion and anxiety (Huelat, 2007). Furthermore, first time visitors in a hospital may not understand clinical nomenclature and how destinations are named (Devlin, 2014). Too often, destinations are identified with bureaucratic jargon and meaningless insider acronyms that make it impossible for a layman, first time visitor to understand (Smith, 2002). In most severe cases, these mounting circumstances caused by disorientation in a complex service environment can lead to feelings of helplessness, hypertension, migraines and physical fatigue. Cancer patients are especially sensitive to high levels of stress produced by disorientation as they have difficulty coping with uncertainties of diagnosis (Huelat, 2007). Inability to self-navigate in an unfamiliar space can dramatically affect a cancer patient’s sense of self control (Carpman, 2002). The consequence of a lost patient can deplete their own emotional, physical and cognitive resources (Huelat, 2007).
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The navigational experience in a hospital is vitally important as this is the one of the patient’s first interactions with a health care institution. Early interactions navigating with a new space are so important, that it can significantly affect how they perceive their overall treatment. Due to the fact that few patients possess clinical knowledge to judge staff on their diagnostic skills, the patient will rely heavily on aspects of navigating the physical environment to assess their satisfaction and overall quality of care (Becker, 2008). Thus, touch-points like congested, confusing corridors produce negative impressions about the larger organizational culture of a health system (Smith, 2002). Patients who experience extreme disorientation may generate hostility towards the health care facility (Carpman, 2002). Health care providers realize there are significant consequences when patients get lost in their hospitals.
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Competition in Health Care As part of patient centered care, health care institutions are increasingly focusing their attention on providing positive non-clinical experiences in conjunction with delivering positive health outcomes. Providers yearn to create an image that shows concern for patient convenience, promptness, responsiveness to individual needs. The twenty-first century health care climate has brought an onset on new challenges to the health care provider industry. Such challenges include rising health care costs, competition over government funds, and rapid technological breakthroughs that have shifted patient populations from inpatient to outpatient settings. As challenges rise, health system administrators are evaluating every aspect of their operations (Becker, 2005).
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While environmental factors in the physical health care space become more complex, emphasis on patient experience and satisfaction grow exponentially (Hutton, 1995). Providers realize that they must place emphasis on providing environments that facilitate a place of well-being. Importantly, competition in the health care industry has spawned a consumer society that demands healing environments where quality clinical treatment is provided, and where patients’ fears and anxieties are soothed (Becker, 2008). Under the competitive health care environment, patients who feel they are not receiving adequate health care will be prompted to look for treatment elsewhere.
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Bottom Line: Patient Perception and Effects on Patronage and Referrals In other service industries such as hotels, shopping malls, and transportation hubs, physical environments have long been recognized to have powerful effects on the attitudes and behaviors of visiting customers (Becker, 2008). Now, hospital environments realize their physical environments play an important role in improving patient health outcomes (Hutton 1995). For years, stakeholders considered the hospital environment to be a soft indicator of perceived performance. Today, the environment is unanimously considered to be a valuable commodity to attract new patient-customers (Becker, 2008). Studies show a patients initial reaction to the physical environment can promote positive or negative interpretations of perceived performance by the health care organization. When patient expectations of the physical environment do not match the excellence of treatment, perceived performance is damaged (Hutton, 1995). Environmental factors have a direct correlation with patient loyalty. If the patient has a negative interaction with the physical environment they may seek care at another facility. Poor environments can negatively impact the customer base, while damaging the hospital’s revenue share (Becker, 2008). Conversely, if the patient’s disposition towards the environment is positive, then the likelihood of patronage is increased. Hence, there a strong correlation between positive patient perception of the hospital environment and higher patient loyalty (Hutton, 1995).
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Research shows that the most powerful way to measure their willingness to receive treatment at the facility again, is their likelihood to recommend care to a friend or loved one (Becker, 2008). Since patients and caregivers look for tangible evidence, such as environmental interactions during their visit, their experience through the physical space impacts word of mouth advertising for provider switching. (Smith, 2002) At the Perelman Center for Advanced Medicine, a patients navigational experience can impact their overall perception of their treatment (Smith, 2002). Environmental pitfalls such as the atrium elevator, although a seemingly innocuous problem, can become a primary driver on how the patient forms a negative image of their treatment and the University of Pennsylvania Health System, as a whole (Smith, 2002).
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Bottom Line: Patient Hospital Scores and Funding Patient perception of the physical environment plays into the value-based purchasing initiative that is now required under the Patient Protection and Affordable Care Act. As part of a national health care reform initiative enacted in 2010, patient perception of care will be surveyed under the Hospital Consumer Assessment of Healthcare Providers and Systems – otherwise known as HCAHPS (Zusman, 2012). HCAHPS scores have a direct impact on government-funded subsidies and health care reimbursement for hospitals across the country. The HCAHPS survey gives health care providers an incentive to increase patient satisfaction with an estimated $850 million up for grabs. How the money is distributed is based on the performance of several qualitative measures, including the hospital’s cleanliness and overall environment (Zusman, 2012). The HCAHPS survey of twenty-plus questions does not explicitly ask the patient about their navigational experience and success finding their way through the building. However, scores from the Methodist Hospital in Henderson, Kentucky demonstrate that enhancing their wayfinding strategy improved scores (Huelat, 2007). Conversely, patients will voluntarily mention navigational pitfalls as one anonymous patient candidly expressed “I felt like I was being pushed through a cattle chute.” Conclusively, navigational experiences are reflected through HCAHPS surveys – prompted or not – and can directly impact government subsidies for hospitals across the country.
I felt like I was being pushed through a cattle chute. – Anonymous patient, Press Ganey HCAHPS
Bottom Line: Employee Satisfaction Many industries realize the physical environment have an immediate effect on customers’ attitudes and behaviors. However, new evidence shows environmental factors directly affect employee performance and satisfaction (Hutton, 1995). In the hospital space, lost patients are likely to ignore signage and directories. Instead, patients and visitors resort to asking staff for directions. When a visitor asks for directions from a doctor or nurse, there is a heavy likelihood they are interrupting the hospital employee when they are usually engaged in a more pressing activity. Additionally, these interruptions can be detrimental to the hospital employee’s focus and clinical performance (Devlin, 2014). Employees are continuously interrupted during their work shift by directionseeking patients. Hospital staff at Roskilde Hospital in Denmark indicated that their main source of negative stress was frequent interruptions by patients who were unable to find their way out of the hospital facility (Bunemann, 2012). Another widely cited study among the wayfinding community indicates one hospital spent more than 4,500 staff hours providing directions to lost patients – consummate to the time of more than two full-time positions. Patients who find themselves lost often resort to asking nurses, doctors and medical staff for directional help. These interruptions caused by lost patients and visitors resulted in a wasteful expenditure of over $220,000, annually (Devlin, 2014). Moreover, doctors and nurses are well paid employees who are better off allocating their precious time towards their intended duties, rather than helping lost patients find their way to their desired destinations.
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In a separate study, hospital employees indicated their deliberation to avoid certain hallways at peak times due to the large amount of congestion of lost patients. The same poor patient navigational performance result in lowered morale among the hospital employees as they believed management had the resources to solve the problem. However, there was a perception that hospital executives did not care the navigation pitfalls were worth solving for (Smith, 2002). Hospital employees, from front-line receptionists to neurosurgeons, realize that navigational pitfalls affect the perception of their own performances as professionals. Employees believe poor navigational experiences can have a ripple effect on their compensation through patient surveys. In one study, 27% of 717 medical professionals said their income was threatened by low patient satisfaction scores (Zusman, 2012). In sum, the poor patient navigational performance can directly affect employee satisfaction.
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Why are Health Care Spaces Difficult to Solve For? Navigational problems in the hospital space seem to be an epidemic in itself. Compared to other industries, hospital spaces offer more challenges to its visitors. Kevin Mahoney, executive vice president of the University of Pennsylvania Health System, is studying how visitors navigate spaces in other venues such large hotels and shopping malls. “People can always find the Gap, but it’s not that easy to find Radiology”, says Mahoney (Landro, 2014). Hotels and shopping malls generally remain unchanged for most of their lifespan. However, hospitals must be able to accommodate surges of expansion and undergo waves of renovation influenced by constant technological breakthroughs. On average, health care facilities require renovation every five to ten years (Sprow, 2012). Because of ongoing operational changes, it is nearly impossible for hospital architecture to remain with its original master-plan. Therefore, sustainable hospital spaces must be flexible for shifting methods in health care delivery. Hospital spaces are inherently unique as they are designed to provide treatment over a long period of time, but have a very small window in how that treatment is delivered. If a hospital is designed as a rigid, perfected architectural object, exactly tailored to initial planning assumptions, the health care space will be obsolete by the time the building opens its doors (Sprow, 2012).
People can always find the Gap, but it’s not that easy to find Radiology. – Kevin Mahoney, President of the Penn Medicine Health System
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Architectural plans for health care spaces must account for future renovations and expansion. New equipment, technological advancements, and changes in the way patients receive treatment make the hospital venue unpredictable. For example, today’s exam room may later be part of an advanced oncology unit. Compared to other industries, hospital spaces face a unique challenge in staying up to date.. Since hospitals lack the ability to close, they are fully operational for twenty four hours a day, 365 days a year. In order to be successful, structural design must emphasize a high degree of flexibility to accommodate unforeseen needs and changes in the way health care is delivered (Sprow, 2012). When renovation does occur, it must not impede on current operational efficiency and patient safety.
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Why is the Outpatient Space, Especially Difficult to Solve For? Due to major technological breakthroughs in health care, there is a current trend toward less invasive methods of medical treatment in the outpatient hospital space. New technology and diagnostic tools are making outpatient increasingly popular. Patients prefer the benefits of walking-in, receiving treatment, and walking out hours after their procedure. In comparison to inpatient treatment, the patient does not have to stay over-night, saving time and money. Many health care procedures once traditionally performed in the inpatient hospital space can now be performed in the outpatient space. So much, outpatient ambulatory health care is the fastest area of growth in all of health care services. Over the past ten years there has been a substantial shift of patients moving from inpatient hospital facilities to outpatient facilities like the Perelman Center for Advanced Medicine. To accommodate this shift, renovations are ongoing. Expansion and renovation happen continuously as projects are identified, planned, funded, and executed. This is especially difficult for hospitals like PCAM as they undergo renovations, while keeping its doors open to its current patient population. Buildings layouts that are not flexible and expandable will dramatically disrupt patient navigation and flow. Due to its master plan layout, PCAM has struggled to avoid navigational pitfalls that occur during its expansion.
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Inpatient vs Outpatient Surgery Volume, 1981-2005
60
50
Millions
40
30
Outpatient
20
10
Inpatient 0 1981
1983 1985 1987 1989
1991
1993 1995 1997 1999 2001 2003 2005
Source: American Hospital Association Annual Survey data for community hospitals. Research and analysis by Avalere Health.
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Wayfinding’s Role in the Health Care Environment Wayfinding strives to reduce the number of lost patients and visitors in hospitals by helping them intuitively move toward their desired destinations. Wayfinding provides guiding elements such as maps, signage, interior design shifts, and landmarks to help patients find their way through the bustling, clinical facility. When navigating a building, a patient will encounter numerous rooms, intersections and objects that help them become oriented with their location. There is a long-standing question in the wayfinding community as to what features define a good location-orienting landmark (Carlson, 2010). At Cedars-Sinai Medical Center in Los Angeles, an subtle wayfinding element may be a bakery, new landscaping, banners, or artwork. These elements serve as soft ‘breadcrumbs’ to reassure patients where they are in conjunction with the rest of the facility (Landro, 2014). Windows also afford visual contact with outside landmarks that exist outside of the building (Bunemann, 2012). A more explicit example of a landmark would include Houston’s MD Anderson Cancer Center, where a large tree sculpture helps indicate the pathway to the hospitals diagnostic center, blooddonor center, pharmacy and chapel (Landro, 2014). Intuitive, less explicit cues are favorable for patients. Preferred wayfinding elements function as unambiguous ‘choice points’ (Bunemann, 2012). At these points, the patient engages in ‘progressive disclosure’ – giving patients only the information they need to make the next correct step towards their destination. (Landro, 2014) This strategy is preferable than to providing more information than the patient needs, to reduce the amount of visual noise.
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Certain wayfinding circles, who specialize in designing effective navigational products for health care environments, believe that overlyexplicit navigational cues for patients are not wayfinding elements. Rather, these navigational cues are ‘way-showing’ elements. Hospital spaces run the risk that overuse of ‘pointing signs’ cause a degree of immunity to the directions that they attempt to convey (Bunemann, 2012). This causes an element of visual noise, especially for those who are under mental stress. Patients who are bombarded with directional signage do not have a lot to give attention to. Rather, patients who are bombarded with directional signage have a lot to ignore. Over-saturation of signage and cognitive-heavy directory maps are true measures of the tension between form and functionality. Hence, wayfinding firms and ill patients experience hospital spaces differently (Bunemann, 2012).
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Traditional Methods and the Conventional Mode Wayfinding firms who have adopted the traditional mindset of “doing things as they have always been done” is what renowned author and leading sustainable design advocate, Enzio Manzini, calls the conventional mode of design. The conventional mode promises tangible, satisfactory results that have been accumulated through years of previous experiences, terse knowledge, and initiatory wisdom (Manzini, 2015). The Society of Environmental Graphics Designer’s (SEGD), is a multidisciplinary community that strives to ‘create experiences that connect people to place’. In 2009, SEGD held a wayfinding conference dedicated to the topic of designing effective wayfinding solutions for health care environments. Speakers included wayfinding thought leaders such as Mark VanderKlipp, president of Corbin Design. “As designers, when you walk into an environment, often, you are already designing a solution and you know what you will do” stated VanderKlipp. “We are a graphic design firm. We are not researchers” (VanderKlipp, 2009). Locked in the traditional mindset, many wayfinding firms use conventional design methods. Conventional design in the wayfinding community is built on forty-plus years of experience and wisdom. However, the community may be squandering opportunities to become more effective at tackling complex issues within the health care space.
As designers, when you walk into an environment, often you are already designing a solution and know what you will do. – Mark VanderKlipp, President of Corbin Design
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The conventional design mode functions when a task or design problem has already been done in repetition. Firms who practice conventional design are successful when they have identified a design problem that their organization has seen before, and it’s leadership of designers have an entrenched wisdom in how to process it. Manzini continues “it is empirical knowledge, implicit and initiatory, to be learned by doing and, above all, by watching the master craft and copying his moves�. (Manzini, 2015). Traditional wayfinding firms may be unwittingly working against their own interests as industry leaders. It is common in the design community for innovative solutions to stunted by habitual practice norms in their design circles (Martin, 2009). Traditional design firms who practice the conventional mode are limited in tackling complicated issues and not complex ones (Cottam, 2006). Conventional mode is only sustainable if the status quo does not change. Furthermore, traditional practices are weakened when design problems become more complex over time (Manzini, 2015). In complex service environments like the outpatient hospital space, design problems have become exceedingly complex. Therefore, traditional wayfinding solutions are no longer sustainable. The current model is unsustainable when traditional wayfinding firms design and solve for one or two problems separately (Ulrich, 2004). Navigational design for complex service environments require a break away from the conventional design mode.
Ezio Manzini is an internationally celebrated design strategist who has written extensively about topics in sustainable design. His published books have demonstrated incredible value to the social innovation community and has inspired progressive thinking in the creative field. Manzini reminds designers that all design solutions are interconnected with their environments. When those environments change, the design must have to change with it.
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Time for Change Health care systems have employed traditional design firms to superimpose solutions in effort to make the hospital’s navigational design systems work. This top-down solution is no-longer effective at solving for complex service environments. Outpatient hospitals, like the Perelman Center for Advanced Medicine, have navigational problems that are immune to solutions derived from the conventional mode.
Duct Tape Covered Signage
It is time for a change. A remedy for the modern outpatient hospital building requires breaking from traditional practices of the conventional mode, and adopting innovative wayfinding solutions derived from what Manzini calls the ‘design mode’. Design mode re-imagines the process in which design solutions are created, where new ideas emerge to solve for new, complex problems (Manzini, 2015).
Hiding Out-Dated Signage 54
Signage Over Signage
The featured images demonstrate the inadequacies of the signage in the Perelman Center for Advanced Medicine. Outdated signage is often fixed with patchwork methods such as ducttape placed over embossed lettering, placement of newer signage in front of older signage, deliberate hiding of signage, and supplementation of low-fidelity signage adjacent with higher fidelity materials. As a result, patients have a difficult time digesting the aesthetic disharmony and visual noise of the hospital.
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Problem Statement Hospital spaces are constantly changing to adapt to new needs and functions. Conventional wayfinding solutions tend to not consider and design for change. As a result, patients cannot effectively navigate complex health care spaces. This costs the hospital money, time, and resources. The result is a hodgepodge of navigation systems which lack a holistic strategy that serve no one.
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Intervention Opportunity The practice of human-centered design requires a cultural shift among the wayfinding community. Because many wayfinding firms are set in their ways and see no perceived value in breaking from their expert approaches, design thinking must be applied to guide these organizations through the ‘knowledge funnel’. Once established, wayfinding creatives can gain a long term competitive edge by employing human-centered techniques such as the walking interview. The walking interview accumulates contextual insight in to the patient’s navigational experience through a complex service environment. In addition, robust findings and potential solutions are ideated, which can later be tested through the process of rapid validation. Wayfinding creatives can deliver more impactful and sustainable design solutions by deploying navigational systems that analyze changes patient behavior in order to keep pace with the constantly changing out patient hospital space. Conclusively, the practice of these human-centered design processes can be applied in a cohesive design framework, known as the Double Diamond Model.
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Moving from the Conventional into Design Mode The hodgepodge of navigational systems in the health care space point to a larger cultural problem among the wayfinding creative community. Wayfinding firms, while in the conventional design mode, are attempting to solve complex problems for complex service environments. Traditional approaches of ‘doing things as they have always been done in the past’ are no-longer effective. Complex wayfinding problems require firms to enter Manzini’s ‘design mode’, where in-depth design research on the people being solving for is essential to fulfill their needs. This ‘people-centered’ approach is widely known as human-centered design. Some wayfinding firms are beginning to utilize words from the human-centered design lexicon. Virginia Gehshan, principal at Cloud Gehshan Associates, spoke at a 2016 Society of Environmental Graphic Designers (SEGD) conference. Gehshan’s presentation, titled “Lessons from Healthcare Wayfinding: Human Factors + Building A User-centered Experience”, spoke about complex factors that make the health care environment difficult to solve for. However, Gehshan was asked about the potential values of user-centered research and replied “Although we would love to do comprehensive research, it is not practical” (Gehshan, 2016). For wayfinding firms like Cloud Gehshan Associates, in-depth research is a process that is seen as expensive, time consuming, risky, and not worth practicing. Applied to the health care setting, Gehshan states human-centered design research is even less applicable. “People who come in are generally anxious about their health”, states Gehshan. “They’re trying to get to their appointment... it is not a good time to intercept and talk to them” (Gehshan, 2016)
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In the hospital space, patients and visiting care-takers are facing heavy cognitive and physical burdens as they navigate to their appointment. There is without question a level a courtesy and common decency to not treat patients as design research test-subjects. Furthermore, it is true not all patients are good candidates for research interventions. However, the design practice of intervening and talking with patients is nothing new. Human-centered design interventions – rather, patient-centered design interventions – have proven to be essential resources of information in other design cultures outside of the wayfinding community. Utilizing human-centered design, while conducting interventions with patients, is refuted by Cloud-Gehshan Associates and other wayfinding creatives in attendance at the SEGD conference. Currently, the present perceived value of breaking from conventional design is not worth pursuing. Consequently, benefits of utilizing patients as a resource remains a mystery.
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Applications of Design Thinking By their own admission, there is no perceived value for wayfinding firms to practice human-centered-design research and patient interventions. Similar firms may be stuck in what many design strategist refer to as the ‘mystery phase’ of the ‘knowledge funnel’. In the mystery phase, organizations will abide to traditional Tim Brown, principal at IDEO, is a celebrated design leader in the field of innovation. Brown advocates the value of design thinking and innovation processes to designers and business leaders around the world. As a champion of the human-centered design process, Brown challenges businesses to break from traditional methods by vigorous design research methods with endusers and patients.
methodologies, while considering novel research approaches as insoluble and unworthy of practice. The above short-term business goals trump long-term business advantages and stifle innovative design solutions (Martin, 2009). In order for wayfinding firms to fully embrace human-centered design research, they must break through the uncertainties and risks of the mystery stage. Design thinking helps creative firms safely traverse the knowledge funnel. According to Tim Brown, chief executive officer of IDEO – a world renowned design strategy and consulting firm – states that design thinking “uses the designer’s sensibility and methods to match people’s needs with what is technologically feasible and what a viable business strategy can convert into customer value and market opportunity” (Martin, 2009). In the health care space, design thinking and human-centered design research reveal patient insights and experiences, conceive innovative solutions, and as a whole, re-imagine navigational design for complex service environments. Wayfinding firms can benefit from new and unwavering creative innovative solutions for navigational design systems, while also providing themselves with a long term business advantage (Martin, 2009).
...methods to match people’s needs with what is technologically feasible and what a viable business strategy can convert into customer value and market opportunity. 62
– Tim Brown, Principal of IDEO
The Knowledge Funnel
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Roger Martin’s model, the knowledge funnel, visualizes the process of breaking from traditional choice-making. By breaking away from the mystery phase, where problems are considered untouchable or unsolvable, businesses go through the heuristic process of employing new solutions. Once the complexity of methods is simplified, processes enter the algorithm phase, which can be better managed by organizations in cost, time and resources.
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Benefits of Design Thinking Design thinking has allowed firms, from large organizations like Apple, IBM, and GE to small startups like Zappos, Uber and Airbnb, a heuristic approach to innovate new creative ideas. Design thinking starts by identifying customer insights. Insights directly inform potential design solutions. Complex solutions are simplified and prototyped, which can be tested and validated. The process of rapidly prototyping new ideas speeds up the innovative process, de-risking the mis-allocation of time, money and resources. Under design thinking, mysteries are demystified in the knowledge funnel. Firms can challenge prescribed assumptions that have historically thwarted more effective, sustainable solutions. “By better understanding the needs of those you’re trying to serve and expressing those needs in the form of insights that you develop and prototype, you end up with new and interesting choices” says Tim Brown (Kleiner, 2009). When the designer immerses oneself in the context of the user or patient, they are able to gain empathy, while observing, analyzing, and synthesizing design solutions simultaneously (Cottom, 2006). Applied to solving for contemporary wayfinding problems in the health care space, design thinking allows firms to safely re-imagine navigational design for complex
As a component to synthesizing processes within human centered design practices, utilization of white boards, sticky notes and other low-fidelity materials allows thoughts and ideas to be synthesized in real time. The center image demonstrates the collaborative decision making and story-telling that occurs during team meetings and work session. Design thinking emphasizes the practice of making new findings, problems, and breakthroughs transparent in order to reach desired outcomes.
service environments. This heuristic process provides an opportunity to break from the conventional mode, while utilizing personal empathy towards a patients journey through the hospital environment as a valuable resource.
By better understanding the needs of those you’re trying to serve... you end up with new and interesting choices. – Tim Brown, Principal of IDEO
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Human-Centered Design and The Walking Interview The practice of human-centered design research has revealed the complex experiences of hospital patients (Locatelli, 2015). Methods such as the walking interview capture the patient journey through the hospital, while putting patients’ thoughts, comments and behaviors within the context of the environment Participatory design is a democratic design approach that seeks to involve all stakeholders. HDR, an acclaimed architectural design firm who has been selected to work on an upcoming in-patient hospital at Penn Medicine, has employed novel participatory design methods such as taking doctors, nurses and staff into a simulation space of an actual hospital blueprint. Participants are able to give their feedback in a live contextual manner.
(Locatelli, 2015). The walking interview is an itinerary method. It captures powerful insights in the co-mingled relationships between the patient and environment (Evans, 2010). Because the walking interview is a contextual study, it accumulates more accurate data than what focus groups or surveys acquire. Undoubtedly, there is nothing more factual than actual observed behavior. The walking interview highlights patients’ actual experiences, while minimizing the researcher’s influence on the patient perspective. Other methods like focus groups take the patient out of context and ask for specific feedback. Participants will tell the researcher what they think they want to hear. The ultimate fact is there is a difference in what people say they do compared to what they actually do. The walking interview is a participatory method. This allows for a level partnership in knowledge discovery of problems and potential solutions. Historically, research participants often leaves his or her role and environment to enter the researcher’s environment to identify problems and solutions. With the walking interview, the researcher enters the participants environment, which balances the power dynamic of how problems and solutions are identified. Ultimately, the walking interview informs design decisions that are aligned with patients actual needs, breaking away from traditional, expert solutions (Evans, 2010).
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What Insights Do Human-Centered Design Techniques Uncover That Conventional Methods Miss? Conventional research methods do not accumulate the same rich content that walking interviews generate. Walking interviews prompt meanings and Prototyping is an essential tool in measuring quantitative and qualitative metrics to determine the success of a design. By utilizing low fidelity products, designers can test their assumptions quickly and validate ending design decisions.
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connections to surrounding environments in real time (Evans, 2010). Since traditional sedentary interviews are predicated on the participant’s biographical account of their previous encounters in a given space, their temporal narrative may not be accurate (Locatelli, 2015). Although the narrative of patient experiences are extremely important in problem discovery, they are more valuable when captured in context. Contextual inquiry of experiences provide a vivid flavor of overall storytelling about journey touch-points with concrete accuracy (Miles, 1994). Hence, the walking interview promises greater accuracy in receiving both qualitative and quantitative data (Evans, 2010).
It should be noted that good qualitative data are more likely to lead to serendipitous, ‘aha’ moments that allow researchers to go beyond preconceived conceptions, while generating innovative ideas (Miles, 1994). Importantly, the walking interview lowers cognitive reflection on the participant, lowers factual distortion, and is capable of retrieving nuanced information that would otherwise be unnoticed or forgotten. Hence, the walking interview is more efficient at revealing ‘soft’ nuances the patient experiences in a health care environment (Evans, 2010). Ultimately, the walking interview will obtain more accurate quantitative data such as the length of times routes taken. Additionally, this itinerary method picks up the qualitative nuances of those routes that the participant takes, making it easier for patients to articulate their experience with
HDR is prototyping their master plan for a proposed hospital unit by erecting an actual scale model made entirely out of foam core. Based on stakeholder feedback, they are able to make quick modifications that will inform and optimize the final floor plan.
the environment.
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Wayfinding Elements and the Walking Interview The radiation oncology department at the Perelman Center for Advanced Medicine deployed low-fidelity signage to determine whether patients would take longer, alternate routes to their destination points. It was determined that users followed the low-fidelity signage, validating the creation and investment of higherquality versions of the signage.
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Wayfinding firms who have a sincere interest in practicing human-centered design can employ the walking interview as a primary research technique. Researchers can arrange an appointment with the patient and intercept the individual the moment they enter the hospital space, while following them to their final destination point. Patient interactions with wayfinding elements such as signage, directories, and spatial landmarks can be captured in real time. The wayfinding research can audit whether these existing elements prove to be valuable. Additionally, wayfinding firms can prototype new wayfinding elements such as low-fidelity signage. With the walking interview, the effectiveness of these brainstormed elements can be validated by observing how patients interact with them. Firms can cheaply and quickly determine whether brainstormed wayfinding elements prove to be effective and worthy of manufacturing at a larger scale.
Designing for Sustainability After a wayfinding firm identifies existing wayfinding problems, brainstorms potential design solutions, and validates those solutions through the use of rapid prototyping, it is essential the finalized solution is flexible enough to sustain with the constantly changing complex service environment in the health care space. Traditionally, within simpler, less complex project spaces, the design process ended with a ‘finished product’, whether it was a final deliverable in the form of a thing or service (Manzini, 2015). Today, a cultural shift is required for wayfinding firms to view design process as open-ended. Wayfinding firms must believe that ‘design is never done’, because complex service environments, especially outpatient hospital spaces, operate in a constant state of change. Therefore, contemporary navigational design must look not only to solve for the problems of today’s patient, but continually considers, measures and adapts for tomorrow’s unforeseen challenges. At a 2009 health care wayfinding conference, Craig Berger, of SEGD, states “This
Meta design is an essential component in creating sustainable, longlasting artifacts that live within constancy changing environments. The process of meta design affords constant iterative feedback that seeks to keep up with living systems by serving as a learning mechanism on top of its primary functionality.
is a big problem we have. We get asked all the time for metrics. We have very little (data) on post project information” (VanderKlipp, 2009). The wayfinding community can provide itself leverage by demonstrating their interventions have impact by augmenting concrete post-project data. Moreover, ongoing data collection, otherwise known as meta-design, will be a necessary step in guaranteeing sustainable, long-lasting wayfinding solutions for complex service environments.
This is a big problem we have at SEGD. We get asked all the time for metrics. We have very little on post project information. – Craig Berger, Society of Environmental Graphic Designers
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The British Design Council’s Double Diamond Framework
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“The Double Diamond diagram was developed by the British Design Council in 2005 as a simple graphical way of describing the design process. Divided into four distinct phases, Discover, Define, Develop, and Deliver, the diagram maps the divergent and convergent stages of the design process, showing the different modes of thinking that designers use.” (Design Council, 2005)
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Human-Centered Design Framework Human-centered design provides wayfinding firms with innovative research methods. Processes such as the walking interview gather valuable, contextual insight. Rapid prototyping validates design solutions quickly and cheaply. Sustainable, meta-design deliverables track patient behavior, and adjust to new, unforeseen navigational challenges. Thus, human-centered design can provide wayfinding firms with a competitive edge by delivering proven, durable, and long lasting navigational systems for complex service environments like the Perelman Center for Advanced Medicine. To solidify the human-centered design process, application of The British Design Council’s Double Diamond Framework align the three methods in a stepby-step configuration. The framework provides a graphical understanding for wayfinding firms to think divergently and convergently in the appropriate stage of a project. The model maps the creative process in two main stages and four sub-phases. The first diamond includes discover and defining, where insights of the walking interview are captured and validated through rapid prototyping. The second diamond includes developing and delivering, where elements are refined and deployed. To fit the needs of the constantly changing complex service environments, meta-design compounds the values of delivering a product or system that has learning mechanisms baked in to the solution. This wayfinding design framework, titled EmpathyPath, re-images navigational design for complex service environments to ensure solutions are effective, proven, and sustainable for spaces like the Perelman Center for Advanced Medicine.
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EmpathyPath Design Framework
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Thesis Statement EmpathyPath is a user-centered and participatory design research framework that helps design professionals create effective and sustainable wayfinding systems for complex service environments like outpatient hospitals like the Perelman Center for Advanced Medicine.
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Project Concept & Process EmpathyPath will exercise human-centered design research methods, while breaking away from conventional navigation design processes. First, EmpathyPath will capture contextual navigation-experiences of the ambulatory patient at the Perelman Center for Advanced Medicine (PCAM). These experiences will be captured as they occur in real time, while accurately accruing rich data touch-points. Touch-points will be compounded with baseline information collected in a questionnaire booklet to delineate a full understanding of what PCAM patients are experiencing as they navigate the hospital. These findings will directly inform effective and sustainable wayfinding solutions to accommodate the constantly evolving hospital space. Solutions will be prototyped, tested, and backed by qualitative and quantitative evidence. Importantly, EmpathyPath seeks to re-imagine navigation design so that solutions are sustainable, responsive, and flexible with constantly changing complex service environments.
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Pilot Launch at the Perelman Center for Advanced Medicine EmpathyPath launched a two-week research pilot in the Spring of 2016 at the Perelman Center for Advanced Medicine (PCAM). The pilot developed a partnership with practicing manager Jessica Tindall and Michelle Sparrow, director of operations at the Abramson Cancer Center (ACC). With their support EmpathyPath collaborated with ACC cancer-patients to contextually capture navigational pitfalls for first-time PCAM visitors. The first desired outcome of the pilot was to discover qualitative and quantitative information relative to navigational experiences for ACC cancer patients. Second, the pilot aimed to demonstrate the effectiveness of the walking interview as a viable design-research method, while demonstrating it’s potential value to wayfinding design practitioners. The ACC helped facilitate the enrollment of qualified candidates in preparation to perform walking interviews. Patients or care-taking family members called the ACC to schedule their first appointment. Qualified callers – specifically, those who would be visiting the health care facility for the first time – would be informed and invited to participate in the pilot. Participants were reminded their feedback could directly inform improvements to their patient experience and for other visitors receiving treatment at PCAM. In sum, nearly twenty people volunteered to take part in the walking interview after a one week enrollment period. Due to time constrains, the pilot would solely focus on validating the effectiveness of the walking interview – the first phase of the EmpathyPath framework. The pilot would not practice the second and third phases of the EmpathyPath framework as these areas would be studied in later pilots.
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The Step-by-Step Process of the Walking Interview Conducting walking interviews takes teamwork and coordination between the design researcher and the partnering clinical department. EmpathyPath codesigned an enrollment and participant-intercept strategy with the ACC to ensure the walking interviews were performed with volunteering participants. A step-bystep process was designed to operationalize the walking interview, while ensuring time and allocation of resources were maximized for both the design researcher and cooperating facilitators at the ACC. After enrolling in the pilot, a patient or caretaker received a confirmation email from an ACC representative. The email explained the walking interview process, reiterated the purpose of the pilot, and provided the participant with a brief instructional overview of their role in the study. Additionally, the email served as a reminder for the email-copied researcher to schedule their time accordingly to the patients date and approximate time of arrival at PCAM. The day prior to the patient’s appointment, the researcher called and introduced himself to the participant. During the greeting process, the researcher retrieved baseline information about the participant’s age, gender, and whether they were the patient or caretaker. The researcher finalized the conversation with a screening of the participants navigational aptitude. Participants were asked to rate their general navigation and wayfinding abilities from a scale of one through seven. The responses during the screening process were recorded. The screening dataset determined how the participant perceived their overall navigational abilities and respective wayfinding behaviors.
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The day of the patients appointment, the researcher deployed a text-message to the participant as a reminder to call or text at the moment they arrived at PCAM. This simple text message enabled the researcher to meet the participant at one of the many entrances to the building. It should be noted that a successful researcherparticipant intercept is a complicated hurdle, as three intercepts failed during the two week pilot. Last minute appointment cancellations and ‘no-shows’ were an additional impediment to the study. EmpathyPath emphasizes the fact that participants were actual cancer patients - participants were not actors or focus group volunteers. Participants included caretakers who arrived to PCAM with their loved-one. Upon greeting the participant’s party, the researcher quickly re-explained the walking interview process. Clickers were handed over to the participants so that they could identify navigational pitfalls during their walk. Finally, the researcher started a timer and stated the walking interview had officially began.
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________
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Patient /Family Caretaker Parking Front Garage Entrance
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EmpathyPath utilized a set of low-cost 4contextual and 3 both tools to capture : 1 2 of y rt Pa _ ____________ recounted information of user behavior. Start Time:__ __ researcher organize ________the The form ____helped ____________ __ __ __ __ __ ________ the participants movements, actions, 1. __________ ____ and__ comments during the walking ____________ ____________ __ __ __ __ __ ____ 2. __________ interview. Importantly, navigational ________ ____ and ‘click points’ were recorded __________ __pitfalls __ __ __ __ __ __________ 3. __________ on the document as they occurred in ____________ ______By ____time. capturing occurrences ______real __ __ __ __ __ ______ 4. __________ contextually, the researcher was able to ____________ __________events __ __ __ document with an utmost level __ __ ____________ 5. __________ of understanding and__done so without ____________ ________ __ __ __ __ __ relying on historical recall. __ __ ________ 6. __________ ______ ____________ The researcher also utilized a stopwatch ____________ __ __ __ __ __ ____ 7. __________ application on his smart phone. The ____________the precise travel stopwatch determined ____________ __ __ __ __ __ __________ 8. __________ times of the patient from the entrance __________ ______ ______ point to__their desired destination at the ____ __ __ __ __ __ ______ 9. __________ ACC check-in desk. __________ ____________ __ __ __ __ __ ____________ 10. __________ __ ____________ uration:_____ D _ __ __ __ __ ________ The letter-size participant form captures End Time:__
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patients and caretakers actions and dialogue, while keeping track of all the ‘click-points’ that occur during the walking interview. The form provides a templated framework to optimize note-taking for the collected contextual data, ensuring all nuanced actions and participant commentary are recorded.
Pitfalls and ‘Click-Points’ The clicker was introduced to the pilot with the assumption that participants may be hesitant to verbally communicate and/or reluctant to admit they were lost. The clicker attempts to ‘break-the-ice’. It acts as a proxy for users to indicate that they are lost, frustrated, or confused. Instead of a participant feeling the defeating sense of verbally saying ‘I am lost’, the clicker changed the nature of the concession. Instead, the clicker served to ‘count’ moments of encounters with the building’s lack of environmental legibility and poor wayfinding elements. Some patients were more inclined to click than others. The researcher used his discretion to remind participants to click whenever they experienced a navigational pitfall. It was important for the researcher to re-emphasize the building was being tested and measured and not the participating patient or caretaker.
The clicker is a low-cost tool that can be purchased at any novelty or pet store. The clicker, which makes a satisfying clicking noise, sits comfortably in the patient or caretakers hand making the action of clicking easy both healthy and ill participants.
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Capturing Information As participants navigated PCAM, the researcher took notes on the customized note-taking form. The researcher keenly observed participant’s behavior, comments, click-points, and nuanced body language. Notes were quickly scribed to ensure wayfinding decisions and navigational pitfalls were precisely captured. Participants utilized the clicker at moments they encountered a navigational pitfall sourced by inadequate signage, confusing floor naming conventions, or misguided directions given by staff. A click would prompt the researcher to ask the participant what motivated them to click. By catching the navigational pitfall as it happened live, the participant was able to reflect on their surroundings with precision and accuracy.
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Comments were kept brief and deeper discussions about certain click-points were reserved for discussion when the walking interview concluded. It is important in any research study for the observer to not impede on the natural behavior of a participant. The researcher should use empathy, good judgment, and common sense when and when not to intervene. The journey concluded once the participant reached the ACC check-in desk. The researcher and participant recapped the journey in the ACC waiting room. The participant received a questionnaire booklet, which contained additional questions about their navigational experience. The participant was reminded to fill out the booklet – typically during their inevitable downtime in the waiting room – and submit the completed document to the ACC staff. As a sign of gratitude, the participant received a complimentary parking voucher for their efforts.
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Participant 1 Interview The first participant arrived in a group of three from Princeton, New
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Jersey. The lead participant was the caretaker of her father who was recently diagnosed with cancer. The researcher
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intercepted the group at the parking level 2 elevator hub. The lead participant
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immediately committed her attention to the directory outside of the elevator, while looking for ‘Abramson Cancer
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Center’. The participant explained ‘theres no indication of what I am looking for’
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and proceeded to click the clicker. The participant’s click marked the pilots first captured navigational pitfall. The group encountered a total of four directories that failed to provide
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the information they were seeking. Unprompted, the lead participant indicated she was she had an internal
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GPS system on her smart phone to navigate the building.
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Participant 2 Interview The second group, like the first group of participants, included a caretaker who
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lead her mother and recently diagnosed father to Philadelphia from Scranton. The researcher intercept occurred on
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parking level two. Interestingly, the participant had written the parking level
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on her hand. This immediately raised the question as to whether the hospital can provide patients with a more intuitive
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way for visitors to remember where they parked in the building.
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The group took an unnecessary detour on the ground level to find a
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temporary directory made out of foam core. Immediately after looking at the directory, the group lead re-affirmed the
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signage was correct with a hospital staff member. Her action raises an interesting question as to whether visitors trust
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personable staff more than the signage that is provided to them.
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Participant 3 Interview Participant three included a middle-aged gentleman who was recently diagnosed
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with cancer. The gentleman was clearly distraught and nervous. He was momentarily guided by his wife, until her
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fear of using the elevator prompted her to take the stairs.
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Participant three had the most clickpoints during his journey to the ACC. He
Participant 5
had a difficult time clearly identifying where radiology was located, as there are many variations of radiology at PCAM.
Participant 6
The participant clicked a total of nine times, four of which took place at the
Participant 7
parking garage. This raises the question as to whether the hospital should provide better navigational assistance at early
Participant 8
entrance points of the building. Ironically, although she took the stairs,
Participant 9
the participants wife arrived at the ACC check-in desk before he did. This factoid demonstrates the extremely long wait times for atrium elevator users.
90
Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
91
Participant 4 Interview The fourth participant, also recently diagnosed with cancer, arrived with great
Participant 1 Participant 2
urgency to reach her doctor. She was accompanied by her husband and friend. The group met at the first parking level of
Participant 3
the building. The group exited the atrium elevator prematurely to the ground level,
Participant 4
then utilized the atrium escalators to arrive at the first floor of PCAM. At this point, the group was confused as to what
Participant 5
level they were on. Without being prompted, the group
Participant 6
commented on the overwhelming amount of directory-signage saying ‘boom, boom,
Participant 7
boom.... signage is just everywhere’. The group indirectly identified the amount of visual noise that occurs in the building. As the group finally arrived to the ACC check-in desk, they had commented
Participant 8 Participant 9
the building should provide first time visitors with their own personal guide to help them navigate the building.
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Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
93
Participant 5 Interview Participant five arrived with her son and Participant five arrived with her son and
Participant 1 Participant 2
recently diagnosed husband. The group arrived through the main entrance after utilizing the valet parking service. The
Participant 3
researcher intercepted the group at the main entrance and moved with them
Participant 4
toward the main atrium elevator. Mostly, the group struggled with the
Participant 5
naming conventions of the building levels. Having entered the building from the street, they assumed they were on
Participant 6
the first level. Taking the elevator up one floor, the group nearly exited onto the
Participant 7
first level, assuming they had arrived on the second level. This insight underlines patient’s unfamiliarity with referring the
Participant 8
first level as ‘ground’. Having successfully arrived on the
Participant 9
second level atrium, the group struggled to identify and read the ACC’s awkwardly designed vertical signage.
94
Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
95
Participant 6 Interview Participant six had a unique destination point in comparison to the other ten
Participant 1 Participant 2
participants in the pilot. As a patient recently diagnosed with lung cancer, she was directed to arrive at the Lung
Participant 3
Cancer Center on the first level, instead of arriving at the ACC check-in desk on
Participant 4
the second level. Like the rest of the participants,
Participant 5
participant six was accompanied by a fellow caretaker. Additionally, she was equipped with a set of hand-written notes
Participant 6
to direct herself through the building. Remarkably, the Lung Center has a
Participant 7
designated ‘navigator’ who provides first time patients with over-the-phone directions. The participant utilized the
Participant 8
directions effectively and encountered just one navigational pitfall. Her performance navigating the building,
Participant 9
in comparison to many of the other participants in the pilot, was much improved.
96
Participant 10
2
Check-in Desk
1
G
Main Entrance
P1
P2
P3
Click-points
97
Participant 7 Interview Participant seven included a caretaking wife and a husband who was also
Participant 1 Participant 2
recently diagnosed with cancer. Unlike the other participants in the pilot, the participant was very familiar with the
Participant 3
building and had indicated she had been to the building before. The participant
Participant 4
indicated ‘we’ve been here for years, but if you come here for the first time, it can be confusing.’ The group navigated the building with expedition and confidence despite the
Participant 5 Participant 6
husbands physical ailments. Having arrived in the ACC through the main
Participant 7
atrium entrance, the group knew they needed to pass the first check-in desk and instead register at the second. As the
Participant 8
participant indicated, ‘I know you have to keep going by first desk’. She inferred that many people at the first check-in
Participant 9
desk were unknowingly at the wrong registration location.
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Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
99
Participant 8 Interview Participant eight arrived with his caretaking wife. At the intercept, the couple
Participant 1 Participant 2
had indicated they had a difficult time finding the parking garage and spent nearly forty-five minutes circulating
Participant 3
the building. This insight underlines the important of successful navigation
Participant 4
outside of the building as well as inside. Although the scope of the EmpathyPath pilot was to measure the environmental
Participant 5
legibility of PCAM and to determine patient’s wayfinding habits, the pilot
Participant 6
inadvertently discovered navigating pitfalls that occurred during the patients commute to and in the city. Participant eight received directions from staff to use the west pavilion
Participant 7 Participant 8
elevators via the ground floor. This route, previously blocked off, is now open for patients. Importantly, this efficient route
Participant 9
is widely unknown to patients who’s final destination is the ACC check-in desk.
100
Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
101
Participant 9 Interview Participant nine was arguably the highest performing navigator in the
Participant 1 Participant 2
pilot. Having been to the building for the first time and being recently diagnosed with cancer, the gentleman incredibly
Participant 3
navigated the building successfully without consulting signage or directories.
Participant 4
Instead, the participant memorized an online directory and map of the building.
Participant 5
During the screening phone call, the participant indicated he was a former police officer and was highly proficient
Participant 6
at navigating new, unfamiliar spaces. He also indicated his vertical and horizontal
Participant 7
orientation was likely higher than most other people.
Participant 8
The participant lived up to his words and successfully reached the ACC checkin desk with little assistance, while
Participant 9
not encountering a single navigational pitfall. Not a single click was heard during this walking interview.
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Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
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Participant 10 Interview The final participants in the pilot included a recently diagnosed cancer
Participant 1 Participant 2
patient and his wife, who was the lead participant. The group met in the main atrium and was quickly greeted by the
Participant 3
hospital staff. The participants knew they needed to arrive at ‘oncology’, but were
Participant 4
unable to indicate what precise oncology department they were looking for. Because PCAM has a total of eight unique
Participant 5
oncology departments, it is common for patients and visitors to arrive at the
Participant 6
wrong oncology destination. Having finally arrived at the Abramson
Participant 7
Cancer Center department, the participants made the mistake of arriving at the wrong check-in desk. As a result,
Participant 8
the patient waited nearly four minutes in line only to be told to go to the other desk. This contextual evidence reinforces
Participant 9
the statements made by the ACC staff that patients are regularly checking-in at the wrong desk.
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Participant 10
Check-in Desk
2
1
G
Main Entrance
P1
P2
P3
Click-points
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10 Total Walking Interviews
2
Sources of Lost Patients 5
5
Patient
Family Member
8
30% Floor Names
42% Signage
1 10+
4 Parking Garage
6 Valet
9
28% Other
First Time Visitor
Average Time of
Average Times Lost:
Average Times Lost:
Walk: 00:04:21
4 Per Patient
1 Per Minute
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The Questionnaire Booklet To supplement the data that was recorded during the walking interviews, the questionnaire booklet provided as an asynchronous information-gathering tool. The booklet captured information such as the participants age, gender, and number of times they had been to the Perelman Center of Advanced Medicine. Recipients of the booklet included all of the ten participants in the walking interview. Additionally, booklets were distributed at the ACC check-in desk to accumulate a larger data-set of information. Large scale distribution of the booklet afforded the researcher to access information from more participants, but with less contextual insight. The booklet served two additional purposes. One, to document information captured during the phone screening. Two, to determine the value in gathering information solely through an asynchronous method.
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LET’S IMP ROV E YOU R PAT IEN T EXP ERIE NCE Ques tionn aire Book let
The Questionnaire Booklet, titled “Let’s Improve Your Patient Experience”, aimed to supplement the data gathered from the walking interviews. The twelve-page booklet was printed and folded in-house on letterhead paper.
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Self-Evaluation Synthesis On page two of the questionnaire booklet, participants were asked to measure their general navigational performance (general sense of direction, map reading, willingness to ask for directions when lost) from one through seven – seven being the highest level of performance, one being the lowest. On page five, the same set of underlying questions were presented, but the questions were applied to their experiences after navigating the
(Please circle 1-7 that applies best)
1. I am very good at giving directions. strongly disagree
1 2 3 4 5 6 7
strongly agree
2. I am good at reading maps. strongly disagree
1 2 3 4 5 6 7
strongly agree
3. I am okay with asking for directions. strongly disagree
1 2 3 4 5 6 7
strongly agree
4. Generally, I have a good sense of direction. strongly disagree
1 2 3 4 5 6 7
strongly agree
5. Usually, I use signs to navigate spaces. strongly disagree
1 2 3 4 5 6 7
strongly agree
6. I tend to forget where I leave things. strongly disagree
1 2 3 4 5 6 7
strongly agree
7. It’s important for me to know where I am. strongly disagree
1 2 3 4 5 6 7
strongly agree
8. I usually remember new traveling routes. strongly disagree
1 2 3 4 5 6 7
strongly agree
Perelman Center of Advanced Medicine.
pg 2
Trends clearly indicate that participants ranked themselves significantly lower during their navigational experiences at PCAM, as five out of six questions indicated higher performance in general evaluations. In particular, participants indicate they generally use signs to navigate spaces, but do not at PCAM.
(Please circle 1-7 that applies best)
1. I would feel comfortable giving someone directions at the Perelman Center. strongly disagree
1 2 3 4 5 6 7
strongly agree
2. I knew where I was going on my way to the Abramson Cancer Center. strongly disagree
1 2 3 4 5 6 7
strongly agree
3. I relied on maps, signs and directories more than people for directions on my way to the Abramson Cancer Center. strongly disagree
1 2 3 4 5 6 7
strongly agree
4. I have a strong sense of direction in the building. strongly disagree
1 2 3 4 5 6 7
strongly agree
5. I can remember what entrance I arrived at the Perelman Center. strongly disagree
1 2 3 4 5 6 7
strongly agree
6. I knew when I had arrived at the Cancer Center. strongly disagree
1 2 3 4 5 6 7
strongly agree
7. Upon leaving the Cancer Center, I know which way to exit the Perelman Center building. strongly disagree
1 2 3 4 5 6 7
strongly agree
pg 5
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General Navigation Self-Performance Rating vs. Navigation SelfPerformance at the Perelman Center for Advanced Medicine 7 6.3 6
5.8 5.3
5
Rating (1-7)
5
5
5.2
5.2 4.7
4.6
4.3 3.5
4
3.5
3
2
1 I am good at giving directions.
I am good at reading maps.
I okay with asking for directions.
Generally, I have a good sense of direction.
Usually, I use signs to navigate spaces.
I usually remember new travel routes.
I would feel okay providing directions in PCAM.
I used maps and directories to get to the ACC.
I used aid of people more than signs to get to the ACC.
I have good sense of direction in PCAM.
I used signs more than people to arrive at the ACC.
When I will leave PCAM I know what way to go.
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Desk Naming Synthesis The Abramson Cancer Center check-in desks collectively accommodate over two-hundred patients a day. First time patients struggle to check-in to the appropriate desk that corresponds with their doctor, as both locations look very similar and lack designated signage. The questionnaire booklet attempts to measure the legibility of the two checkin desks from the perspective of patients
Eastern Desk
and caretakers. The first major takeaway from the data indicates that both desks look familiar to participants. Yet when asked what each desk was called, participants overwhelmingly responded with a generic answer; answers such as ‘checkin desk, receptionist, and registration were most common. This lack of designation can attribute to the fax that first time patients have a hard time finding their way to the appropriate registration destination.
Western Desk 112
Eastern Desk
Does this space look
Western Desk
3
1
No
No
17
3 What would you call
1
1 N/A
Specific Answer
4 14
Specific Answer
13 Generic Answer
Generic Answer
1
3
or object located?
Yes
N/A
this space or object?
Where is this space
20
Yes
familiar to you?
N/A
Specific Answer
17 Generic Answer
20 Generic Answer
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Landmark Review Synthesis The questionnaire booklet evaluated a peculiar piece of art that sits outside of the Abramson Cancer Center (ACC) and the main atrium elevators. Patients and caretakers who arrive at the ACC most likely walk by this artifact during every visit. However, when participants were asked if the space looked familiar, only a small fraction indicated that they had seen the landmark before. Quite simply, patients and caretakers do not take notice of it. When asked what a participant would call it, only a fraction responded with a synonymous response. In sum, patients and caretakers would have a time articulating what they would call the landmark if they were to try to use it as a direction-giving element – making this strange oddity a poor artifact on the wayfinding landmark scale.
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5
Does this space or object
Yes
11
look familiar to you?
5
Not Sure
No
3 What would you call
Obelisk
7 Not Sure
this space or object?
5 Other
3 Where is this space or object located?
Other
4 2nd Floor
12 Not Sure
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Elevator Review Synthesis The questionnaire booklet determined to measure the familiarity of the elevator and ability to be utilized as a strong wayfinding landmark. The data indicated that participants in the questionnaire overwhelmingly recognized the elevators and were able to synonymously refer it as either the ‘main’ elevators or the ‘atrium’ elevators. Patients and caretakers are able to identify the main elevator core due to it’s contrast from the monotony of the soft-beige colored building. The contrast can be attributed to the natural light that stems through the glass. Out of all the wayfinding elements in PCAM, it is arguable the atrium elevators are the most recognizable and effective in helping patients and visitors navigate the building’s space.
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2 Does this space or object
2 N/A
No
17 Yes
look familiar to you?
2 What would you call
2
N/A
Doors
14
this space or object?
Elevato rs
2 N/A
Where is this space or object located?
8
10
Wrong Answer
Correct Answer
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Local Orientation Synthesis
Where do you think you are located in the Abramson Cancer Center? Place a mark on the map to indicate where you are.
As part of testing the environmental legibility of the Perelman Center for Advanced Medicine, participants were Atrium Elevators
asked to place a mark on their local orientation within the Abramson Cancer Center. Due to the fact participants filled
West Pavilion Elevators
out the questionnaire booklet away from the design researcher, it is unclear
ATRIUM
whether patients answered correctly. However, the data shows many patients indicated they were situated in one of the patient rooms. pg 11
If patients were accurate in their local orientation, the data demonstrates patients filled out the booklet in both waiting rooms and examination rooms. Additionally, three participants explicitly indicated they were not within the Abramson Cancer Center and placed themselves ‘off the page’. This suggests that some of the participants had above average local orientation within the ACC.
118
Atrium Elevators
West Pavilion Elevators
ATRIUM
Self-Location Marks
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The Questionnaire Booklet Closing Key Insights The questionnaire booklet proved to be an effective asynchronous data collection tool to be supplemented with the data-set from the walking interviews. During EmpathyPath’s two-week trial at the Abramson Cancer Center, the questionnaire booklet attracted over twenty participants; nearly twice the amount of people that participated in the walking interview. The data the booklet received was particularly insightful in terms of understanding the nomenclature of particular landmarks within the Perelman Center for Advanced Medicine. Though, compared to the walking interview, there was little opportunity to follow up on participant responses. Since the booklets were completed with historical reference, answers may have lacked accuracy.
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Are you the patient
5 Caretaker
or caretaker?
15 Patient
3 How many times have you been to PCAM?
Twice
10 Ten or More Times
7 First Time
What is your primary language?
20 English
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Cross Pollinating Data The final stage of the EmpathyPath pilot was to synthesize the data collected from the synchronous and asynchronous research methods of the walking interview and questionnaire booklets. The process of cross-pollinating data counter-balances the influences of one method to the other. Undoubtedly, each method is valuable in its own way. The walking interview is more selective and time consuming, but reveals richer, contextual stories of the PCAM visitor. The questionnaire book reaches more participants, but lacks the same level of accuracy and researcher-participant interaction the walking interview provides. To determine actionable an actionable design solution, EmpathyPath overlays highlighted issues from the walking interview and questionnaire booklet. The overlay between the two would ultimately inform the rapid prototyping phase of the EmpathyPath framework.
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Key Insight Overlay
Walking Interview
Both
Questionnaire Booklet
Signage pitfalls Mis-information from staff.
Baseline information (age, gender, etc) ACC check-in desk differentiation
Hidden Routes Department nomenclature Patient stories and backgrounds
Navigational aptitude rating Local orientation
Landmark orientation on the second floor
Landmark nomenclature Check-in desk nomenclature
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Future Considerations EmpathyPath concluded a two week research pilot as phase-one of the thesis framework. The project would devote it’s attention to future considerations in the second and third phase of rapidly prototyping navigational elements and defining sustainable meta-design solutions. EmpathyPath proved the walking interview to be an effective humancentered design research tool in the field of wayfinding. However, it also demonstrated patients and guiding caretakers are willing participants who want to contribute to the improvement of their navigational experiences. EmpathyPath presented it’s collected findings and insights to the Abramson Cancer Center board of trustees. With authorization from the board to continue the pilot, it was time to start ideating solutions for the reoccurring navigational pitfalls that were captured in the first phase of the pilot. Plans for phase two were put in to place. Finally, EmpathyPath advocates wayfinding design practitioners to pivot from the conventional design mode and practice human-centered design research methods, while deploying long-term navigational solutions that are sustainable for the complex service environment.
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Thesis and Pilot Recap The core problem EmpathyPath identifies is outpatient hospital spaces are extremely complex. And like other complex service environments, outpatient hospitals are under a state of constant change and continually evolve for a number of reasons. The complexity of the environments have made navigating these spaces increasingly difficult for visitors. Historically, the traditional approach for health care systems to solve for navigational pitfalls is done by contracting an expert wayfinding design firm. These firms who generally practice the conventional mode of design, often utilize the same approach the previous firm practiced. These practices include updating the content of signage and directories, refining wayfinding elements to boast aesthetic fidelity, and making the state of navigation cohesive again. However, it is apparent the conventional mode of design is not sustainable in the complex service environment.
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Even under the best circumstances where the wayfinding design firm accurately solves for the environments current needs, solutions deployed rarely build the capacity for wayfinding information to be flexible for change. Wayfinding elements fail to be responsive to the constant alterations of the physical environment and rising expectations of hospital visitors. This design process is opposed to where design is heading in other problem spaces of the design world. As demonstrated by firms like IDEO, who employ human-centered design, sustainable solutions seek to build a capacity for clients to be better at addressing their own problems. As a final part of the EmpathyPath thesis declaration, wayfinding design solutions should incorporate built-in systems for learning, while solving for current navigational needs. Additionally, the thesis demands installing navigational systems that evolve with ongoing spatial mutations and increasingly complicated needs of patients like Bob. Essentially, these systems must provide surveillance over how the wayfinding elements are performing over a long period of time. This would be considered as design-reconnaissance, where systems constantly survey, observe, and examine the state of the complex service environment. .
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Presenting Findings to the Abramson Cancer Center In May of 2016, EmpathyPath presented the results of the two week pilot to the Abramson Cancer Center board of trustees. The results of the pilot touched on the findings of the walking interview and the questionnaire booklets, while pointing to potential ‘next steps’ in the EmpathyPath framework. Now that phase one had been completed, it was time to pinpoint potential wayfinding solutions that could be rapidly prototyped and tested to improve navigation and orientation for ACC patients. The ACC board decided next steps should primarily focus on differentiating the two ACC check-in desks. The group also agreed temporarily replacing the landmark outside the ACC would help patients orient themselves on the second floor, which is within the walking vicinity of the department entrance point.
128
Michelle Sparrow gave authorization for EmpathyPath to conduct walking interviews with ACC patients. Michelle is now a part of the discussion of prototyping potential wayfinding elements that were informed by the first phase of the pilot.
Jessica Tindall was the lead collaborator of the EmpathyPath pilot at the ACC. Jessica was an integral figure in scheduling appointments with first-time ACC cancer patients.
129
Differentiating the ACC Check-in Desks The ACC board of trustees gave the greatest reaction to the prospect of differentiating the two corresponding check-in desks. There was a desire to increase patient performance and reduce the number of times the check-in staff would have to redirect lost patients to the correct registration location. With the overwhelming evidence provided by the walking interview and the questionnaire booklets, providing unique nomenclature to these points was a dire necessity. First iterations are to designate the east check-in desk as “A” and the west check-in desk as “B”. With the addition of clearly legible signage and supplementation of color coding system, patients will locate their appropriate check-in location. EmpathyPath will conduct phase two of the pilot, while rapidly prototype multiple solutions and synthesize evidence before declaring a final solution.
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Testing Effective Landmarks The Perelman Center for Advance Medicine suffers from strange, unfamiliar landmarks – and the ACC board of trustees agree. The group talked about temporarily replacing the pyramid-like sculptural landmark, as referred in the questionnaire booklet, that sits on the second floor between the atrium elevator and entrance to the ACC. Effective landmarks surround the University of Pennsylvania Health Care System campus. A rendition of the LOVE sculpture is a popular, high recognizable landmark that sits in a nearby plaza. Pedestrians regularly admire and take pictures with the sculpture for its iconic significance to the city of Philadelphia. However, the LOVE sculpture has served as an effective wayfinding element. Discussions of what temporary form or depiction to be installed outside of the ACC is ongoing. However, the board recognizes what features make a landmark recognizable and an effective wayfinding element.
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Embedding Learning Systems in to Services While the walking interview proved to be a valuable research method – capturing navigational pitfalls contextually with a high level of precision and detail – it indirectly served as a VIP-usher service. Patients, although receiving no direct assistance from the EmpathyPath researcher, thanked him for acting as a guide to the Abramson Cancer Center. For a first time visitor – especially a patient who has recently been diagnosed with cancer – maneuvering through a large, unfamiliar building is done with more confidence when a person simply walks beside them. While an usher type-service may be a viable form of design-reconnaissance, other alternatives may come in more technology based forms. Such elements may include digital signage where directional content can easily be modified and updated to the current state of the building. Moreover, the digital signage could potentially be responsive to the users needs, while tracking what type of information visitors are consistently looking for. This method would not only help the immediate needs of the visitor, but also creates a database of navigational information the hospital can continually survey. The same consideration could be applied to a mobile application that tracks visitors movements and routes taken. An application could embed a ‘help me button’, where a red-coat could recover and assist a visitor. This solution would address the issues of lost and distraught patient or caretaker, but also track precisely where in the environment visitors are struggling the most.
132
Theoretical Model
High Cost
VIP Usher (Walking Interview) Digital Signage
Low Value
High Value
Focus Group
Mobile Application
Questionnaire Booklet
Low Cost
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Red-Coat Opportunity The Perelman Center for Advanced Medicine already staffs the building with a personable work force who don red colored coats. Naturally called ‘the redcoats’, these staff members are stationed at strategic locations of the building to provide navigational assistance. The redcoats are highly valuable and provide a human-element to helping lost people. When cancer ridden patients are stressed out, it is feasible to assume they do not want to navigate a complex interaction with a building when they can simply talk to someone. Moreover, the redcoats are infinitely more versatile in comparison to directional content on stagnant signage. EmpathyPath raises the question as to how a platform could be designed to help the red-coats be part of the design-reconnaissance, while capturing the same level of rich data the walking interview retrieved.
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Closing Statement In closing, EmpathyPath calls for designers to use empathy to truly appreciate the navigational experience of an extreme user like an Abramson Cancer Center patient and family member. Moreover, EmpathyPath calls for a paradigm shift among the wayfinding design community to create solutions which exceed updating existing directional content, and to better help complex service environments better cope with and solve for their navigational pitfalls. Navigational design should create wayfinding elements that are not solely fixated on resolving for current needs of an environment. Rather, navigational design should consider how environments can use empathy to cope with ongoing changes. It may seem counterintuitive for a wayfinding design firm to deploy responsive, sustainable systems that automatically adjust and update themselves. Historically wayfinding design firms have profited on returning to constantly mutating buildings like the Perelman Center for Advanced Medicine. However, if a wayfinding design firm pivots it’s ethos from solely solving for the current state, but also pro-active about solving for navigational problems of the future, they may give themselves a competitive edge amongst their competing design bidders. Empathy is a tremendous research tool. As bestselling author and philanthropist Daniel Pink states, “Empathy is about standing is someone else’s shoes, feeling with his or her heart, seeing with his or her eyes. Not only is empathy hard to outsource and automate, but it makes the world a better place” (Winfrey, 2009). – Daniel Pink, author, A Whole New Mind
Empathy is about standing in someone else’s shoes, feeling with his or her heart, seeing with his or her eyes. – Daniel Pink, author, A Whole New Mind
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About the Author Mike Begley is a passionate designer and critical thinker. Starting his career in the field of visual communication, Mike specialized in print design after completing his Bachelors of Fine Arts from West Chester University with a focus in graphic design. Mike has worked for the Philadelphia Inquirer, ComcastSpectacor, and the Philadelphia Flyers – where he created the 2013-14 season branding campaign for his favorite team since childhood. Mike believes in order to be a successful designer, one must be a perpetual student of the trade. After finishing his dual certification in web design and web development from the University of the Arts, he decided to pursue his Masters of Design from the university. Mike is a proud graduate of the Design for Social Impact program and currently works at Penn Medicine as a Information Experience Designer.
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