Collaboration
During one of the Design for Health Master's program, a collaboration between the Spatial Studio course and the SickKids hospital was formed.The aim of this project was to identify the challenges in SickKids' atrium and propose design solutions. Several observation sessions, one-to-one interviews, presentations and feedback from the healthcare team at SickKids were conducted.
Teamwork
After employing a grounded theory approach according to the data collected from the class members' first observation around SickKids Atrium, 4 teams with different backgrounds were created according to the found themes. This presentation mainly focuses on the wayfinding theme.
Canadian Emergency Departments (ED) receive approximately 200-300 visits a day and nearly 82,000 children and families a year. The very nature of the ED environment and the situations families, caregivers, and patients experience result in high volumes of anxious visitors arriving daily. Moreover, the SickKids ED serves patients, families, caregivers and visitors of diverse populations with a wide variety in age, culture, language, abilities, education, etc. Such a variety of population demands needs that must be addressed.
First Observations
After visiting the SickKids Hospital's atrium, observations were conducted with an evidence-based design approach, note-taking and sketches of the atrium and the ED intake area during different times of the day to capture information on changes in flow and demand. Additionally, three observation points were outlined: Inside the ED, outside the ED doors in the atrium and outside the orthopaedic doors to ensure various points of the journey were considered.
Analyzing Data
Employing a grounded theory approach was used to analyzed the qualitative data gathered to identify the gap themes: (1)Patient Orientation (2) Patient Tracking/monitoring (3) Patient and Staff Comfort (4) Privacy and Safety. After identifying the themes, a thematic analysis approach was used to further classify observations made.
Patient Orientation: Wayfinding
Throughout the research and design process, ED staff such as doctors, nurses and registration staff confirmed the data and results identified were credible and viable. Six key strategies emerged as key areas of consideration: (1) Maintenance and evaluation, (2) Themes, zones, neighbourhoods, destinations, (3)Information, (4)Signage, (5)Landmarks, (6)Structural/architectural.After observations took place, a question was developed for semi-structured interviews with subject-matter experts to clarify any gaps and get different perspectives from stakeholders involved.
The objective of this evidence-based design project was to explore and analyze the capacity and spatial challenges that the SickKids Paediatric Emergency Department (Atrium) faces.
Through qualitative methods, patient orientation (wayfinding) was identified as one of the core components affecting staff, patient, family and visitor experiences. From subject matter expert interviews and observations, three major sub-themes emerged that were crucial to understanding wayfinding behaviour: psychological, environmental and communication. With this understanding, we developed our research question: "How might we re-imagine the Emergency Department wayfinding system to support patient orientation through integrated environmental, psychological and communication plans?"
Observation Findings
The three sub-themes are intimately related and connected strongly one another, which are (1) Environmental, (2) Psychological and (3) Communication. Moreover, observations at SickKids Hospital and various subject matter expert interviews provided evidence that suggested these three components are not a representation of poor staff or management, but rather it's a fundamental and systemic disconnection is a result of a multitude of reasons such as building renovation, outgrowing the space, overcrowding, changing needs, processes and changing demographics and served populations.
Further Observations + Identifications
To understand the gaps in the current wayfinding system at SickKids, observations of the atrium environment were conducted, personas and journey maps were developed, and a space syntax analysis was completed.
To ensure that the team covered all possible standpoints, three observation points were outlined: (1)inside the ED, (2)outside the ED doors in the atrium, and (3)outside the orthopedic doors.
Overlaying Journey Maps
Through observations and secondary research, an overlaying journey map was created to identify that people begin their journey from multiple points such as from their home, school or any other public/private space with the acknowledgement that the way they get to the hospital impacts their journey.
Creating personas based on observations with different journeys to understand more perspectives and challenges faced along their way.
Based on the personas created, a general journey map with touchpoint was created starting from searching for the hospital's or patient's location till their departure from SickKids.
Space Syntax Analysis
The space syntax analysis identified all obstructions with found to be very problematic with the first point of contact with staff at T1 (triage), being out of view. On entry, navigator sightlines include registration and the wall ahead of them. Registration is not clearly identified and the line-up orientation is not intuitive, creating confusion and the question of where to go first remains. The map also identifies decision points and stopping behaviour (feeling confused or hesitant) across journeys and indicated them with red triangles. The green squares indicate where there are visual and verbal cues (signs, information desk, informational maps and directories).
Identifying the problematic areas causing confusion, frustration, errors and delays in navigation and determine areas of high need of intervention, especially in proximity to the ED. Sightline analysis inside the ED showed that the current visual control and accessibility do not benefit staff in controlling certain patients' behaviours and monitoring.
Sight-lined to the waiting area (both inside the ED and out in the atrium) are not visibly accessible to the nurses and registration staff, requiring them to continuously walk around looking for and checking on patients.
This sometimes results in miscommunication between staff and patients and is problematic in life-threatening situations or patients whose status changes quickly without notice. The convex space analysis showed how patients need to go through multiple spaces to do things such as ask a question regarding their status. It also provides insight into other issues such as privacy and the ease of navigation to those spaces. Convex spaces and their connecting directly relate to the number of decision points and the need for navigational support along the way. As a result of this analysis, it was able to correlate the psychological, environmental and communication factors to the physical environment at SickKids and how strategies can be used and placed to support the people using the space.
Wayfinding System Key Areas
The theme development for the system is tied closely with the organization’s brand. It tells a story about the people, the space, culture and the message you want to convey. It does not overpower the functions of the wayfinding system but should support it and bring a positive experience and playfulness to the navigational journey (Fromet, n.d.). Symbolism, messaging, sound and visual essence are identified as key areas that can bring the theme to life for an immersive, multi-sensorial experience. The Key areas identified are (1)zones, (2)neighbourhoods, (3)destinations, (4)transition points and (5)reinforcing points.
Design + Accessibility Standards
Standards and guidelines are implemented for the design, fabrication, installation and maintenance of the signage and information portions of a wayfinding system. The design standards included: (1)continuity, (2)consistency, (3)inclusivity, (4)brand/theme, (5)colour and contrast, (6)typography (7)pictographs, (8)materials, (9)placement, (10)multimodality and (11)viewing distance.
Five Design Guiding Principles
Later on, five guiding principles (1)user experience, (2)effectiveness, (3)inclusivity, (4)sustainability and (5)safety were established to frame the path forward with the design intervention proposals. Ideation sessions backed by secondary research informed the six key strategies to be addressed in re-imagining a new SickKids Hospital wayfinding system: maintenance and evaluation; themes, zones, neighbourhoods, destinations; information; signage; landmarks; and structural and architectural.
Design Approach
A scaled approach was used to define the level of intervention outlined by the 4 following factors:(1) financial cost, (2)resources required, (3)operational interruptions, and (4)timeline. Intervention possibilities were identified at each level in the ability to implement changes. A three-levelled scale of interventions was layered on to upgrade the system in the future step by step.
Hospital Experience
Leveraging the existing SickKids Hospital zones and colours, a new theme is proposed to provide a playful environment through storytelling, symbolism and unity across the hospital experience. The theme to resonate with the larger community outside the hospital since SickKids also functions as a public space set in a specific place within a city, province, country and world. Moreover, indigenous animals symbols are used to highlight the importance of combining Canada's origins and other cultures.
Recognizing the Indigenous History
The City of Toronto and its indigenous history was the starting point of this thematic exploration. The city acknowledges the traditional territory of many nations including the Mississaugas of the Credit, the Anishnabeg, the Chippewa, the Haudenosaunee and the Wendat peoples. This led to searching for further symbolism that exists between the city and its indigenous history. We came across the City of Toronto coat of arms, which specifically uses the eagle to represent its native background, bravery, strength and power and the bear to symbolize strength, determination, and care.
Through further research, identifying additional symbols for the other two zones to tie into the overall nature-based theme that stemmed from the coat of arms animal symbolism. Biophilic design principles played a strong role in this choice as being closely connected to nature helps in the healing process.
Zones and Neighbourhoods
The zone delineation was left unchanged as there was not enough information or knowledge about the rest of the hospital to make any changes that would affect the broader system. However, creating this new theme with the possibility and intention, which could be implemented across the hospital in phases. The Zone names were kept the same as an acknowledgement to the donors and key icons were assigned to each area. The Atrium, where the ED is located, would be the Slaight Bear Atrium. The Hill Wing would be the Hill Hummingbird Wing, the Burton Wing would be the Burton Butterfly Wing, and The Black Wing will be the Black Eagle Wing.
Proposed Visuals
The illustration below shows the breakdown of each zone, the specific symbolism and meaning behind each animal from an indigenous perspective and the associated visual essence and sounds that each zone captures. The ED branding is also shown to indicate its unique appearance for quick identification upon arrival.
Layered Map
Moreover, the illustrated maps show how the layering of the theme applied to zones, neighbourhoods and destinations. In this example, the neighbourhoods appear inside the ED and the destination being the ED entrance. How the theme is applied differs for each. The concept is like telling a story where the entire zone, in general, provides an overview of the bear and its overall look and feel.
The neighbourhoods tell specific stories (or sub-themes) about where the bear likes to spend time (ex. Rivers and streams in the waiting room) or common things associated with bears such as honey (honeycomb theme for triage areas) as shown in the green zoned-map. The exception to this story is the destination (the ED) in some cases where it strays from the bear theme to ensure it is identifiable by common universal indicators such as the colour red, the cross symbol and words “emergency” in bold white letters. On the other side, the red branded t-shirts and visuals are examples of some ED identifiers that could be used as a low-level intervention.
Sounds and Acoustics
Hearing, similar to vision, is a distance sense and can provide information about the environment (Blauert, 1997 in Jancke, L. 2011). Part of the thematic strategy consists of including acoustic themes into each zone. Speakers can be placed at transition points to indicate a zone change and help the navigator recognize where they are and where they are heading The map below shows the Slaight bear atrium would have forest sounds; specifically, the waiting area playing forest and river stream sounds that would also help create a calming sensation. The Black Eagle Wing would play wind, and soft breeze sounds to go along with the flight of the eagle. The Burton Butterfly wing would have sounds of wind and crickets, and finally, the Hill Hummingbird wing would play bird ambient sounds. The acoustic themes create an immersive experience for patients, families and visitors while assisting them in their wayfinding journey. The map below also shows the key transition and reinforcing points across the main floor of SickKids Hospital.
Design Standards Application
Establishing standards is critical for continuity, consistency and inclusivity of the wayfinding system (Steer Davies Gleave + Dialog, 2012). Therefore, following the design + accessibility standards guide established during the secondary research (Continuity, Consistency, Inclusivity, Brand / Theme, Color and contrast ) to set a visual standard for signage is proposed. We suggest that all visual elements should follow these guidelines, themes and proposed branding. Continuity, consistency and inclusivity should be considered in developing the designs across the application of the different strategies as shown in the illustrations below.
The design proposal to SickKids included 3 packages with different levels of interventions applied to the 6 strategies identified as: evaluation, maintenance; theme, zones, neighborhoods, destinations; information; signage; landmarks; and structural configuration. The first two are covered outside of the scaled packages section as they should be combined with the package(s) chosen by the hospital, where pertinent and feasible. The team has created three levels of intervention and included examples of information, signage, landmarks and structural configurations that can be implemented now at SickKids Hospital or in a future state.
- Reduce excessive signage, and ensure its placement supports navigational decision points.
- Use existing recognizable features in the environment to create a point of reference.
- Update all current information sources to reflect up-to-date and consistent information and assess information placement.
- Remove or relocate obstructions that may require minimal to no construction.
Low Level 4 Focused Areas:
Low Level Budget
This package is estimated with a budget of $20,000 to $80,000. This project will involve print shops, contractors for painting, procurement, financial teams, project management and the emergency department and may produce minor operational interruptions.
To improve the users' journey from the point they decide to go to the SickKids ED, navigation aids (e.g. Google maps) should be updated to reflect the closest and available entrances. Currently, taxi and navigation apps like Uber and Lyft show inconsistent information for the ED. Partnering with Google can benefit the sustainability and the continuous development of an app while ensuring information is constantly updated as shown in the 2 examples above. Such collaboration not only benefits users in wayfinding, but the ED staff location updates are required. Google Maps offers several technologies that can be easily integrated into the app at a low cost for high value.
Downloadable
kid-friendly SickKids Maps
Other navigation aids along the journey may include downloadable maps from the SickKids website and the directories on site. Updating current zone maps to indicate correct public entrances and creating downloadable and printable kid-friendly versions could also be used to enhance wayfinding.
Atrium Signage + Landmarks
At this level, signage and landmark examples in the atrium include using the ED red colour around the doorway, re-positioning the ED signage above the doors to increase visibility from Elizabeth Street and using obstructing pillars as opportunities for sign placement.
Signages
(1) Bear prints on the floor indicating where to go first should be used to lead from the ED entrance to the wall mural inside. The mural itself acts as a landmark inside the ED and provides grounds for directional language. The signage and landmark give the navigator the necessary information to begin the triage process while introducing playfulness to the space. (2) Signage at the parking garage and parking elevators are also included in the scope of the low package. Existing signage and information should be revisited. The team has included some examples for reducing information clutter and refining signage at the parking level to reinforce cues to help navigators orient themselves towards the ED.
Exterior Identification
It was also identified that clearer exterior identification is needed at essential touchpoints along the journey, as the SickKids branding and identity are not applied consistently. For example, adding SickKids branding on the exterior that is visible from more vantage points can make the building more recognizable for newcomers. The SickKids branding and identity should be viewable from multiple vantage points along University Avenue.
- Reduce excessive signage and modify and/or install new signage at key decision points
- Implement a new recognizable feature in the environment to create new points of reference
- Update the current information sources, revisit platforms and implement multilingual communication forms and mobile phone based directories
- Review and remove structural obstructions
Medium Level 4 Focused Areas:
Medium Level Budget
This package was estimated with a budget of $115,000 to $500,000. This project will involve contractors, architects, the Emergency Department team project management teams, structural engineering, finance teams, technical support, procurement, designers and translators; and will require moderate operational interruptions. This scale of the project will have a timeline range of 4-9 months.
Digital Information Availability
Updating information on both digital and analogue platforms is crucial. In the medium intervention, we suggest providing multiple forms of information. Information delivery and access can be achieved with a QR code system implemented on orientation maps. This system could include additional information in multilingual or audio-based forms and carried out at key points of entry across the hospital.
Around SickKids' Corners
Within this package, the team suggested placing the directional signage at the 4 corners surrounding SickKids to help point people and cars to the correct entrances based on their destination. The physical placement, sign size and letter height should be based on viewable distances as outlined in the design standards. Following these guides is critical to making the system usable. Material choices should also be considered, such as matte finishes to reduce reflective glare.
Landmarks + Constructions
Upgrading to the medium package will require some construction to create landmarks. Landmarks should be established to allow visitors to quickly see where they need to go. In this level of intervention, the team proposed transforming the current 4-way lamp post sign outside the ED to a vertical 4-way pillar with a bear on top. This creates a landmark for this neighbourhood and reflects the bear zone theme. The placement of the landmark (e.g. where all sightlines from major reference points intersect was carefully curated based on isovist mapping completed after the observations).
Visual Obstructions
Another example consideration in the package is to maximize visibility by removing existing obstructions that block key sightlines. One of the main obstructions is the information desk back wall, which currently blocks the ED doors. Taking the wall down or reducing its height will allow for better visibility to the ED entrance from Elizabeth Street. Another example of obstruction removal is inside the ED. Reducing the area of the registration cubicle can increase visibility and improve sightlines for staff to the waiting area. The sightline maps below show the existing sightlines inside the ED and the revised with signage placement locations identified in red.
High Level 4 Focused Areas:
- Implement recognizable features across the hospital and exteriors that tie into the overall theme.
- Revisit existing signage and modify accordingly across all areas of the hospital, including both interior and exterior) to align with the theme and zone identities.
- Establish multimodal platforms and delivery methods across the hospital and implement new technologies to ease wayfinding.
- Reconfigure ED intake spaces to optimize operations, safety and experience.
High Level Budget
This package is estimated with a total budget of $600,000 - $1.5 million and should be carried out in phases or stages. The project will involve the Emergency Department team, contractors, architects, project management teams, structural engineers, electricians, plumbers, financial teams and a smart parking company. With the scope of this project, the estimated timeframe will be at least 9+ months.
AR Integration
At this level, a SickKids wayfinding app can be used to integrate wayfinding tools such as augmented reality with a navigational overlay on-screen as shown in the Google example below. A study conducted by Kim, M. J., Wang, X., Han, S., & Wang, Y. (2015) suggested that AR significantly reduced the time and cognition workload of human wayfinding behaviours. When it comes to users with special limited abilities, google maps provides options, such as vibrations, audible text, search using voice memos, personalizing text font size, a variety of languages and in the future, AR integration. With that, users can personalize their app to navigate more accurately and meet their needs. In addition, Google can assist the user starting from the first step of their journey (outdoor) until they reach the ED triage (indoor navigation). QR codes, orientation maps, and transportation options in the previous packages should also be integrated into this wayfinding app.
Reconstruction of The ED
This package also includes the ED reconfiguration in the scope. With the reconstruction of the current ED space, wayfinding strategies would be integrated to support the environment where decision points exist and where additional information is required. In collaboration with other groups, the revised floor plan considered wayfinding behaviour to inform structural changes and flow through the space shown in the 3D atrium design example. The objective of this plan is to maximize sightlines and recreate a functional space to accommodate the patients' flow in SickKids ED. The map example indicates all of the places where signage and landmarks should be placed.
Feasibility
Some of the proposed interventions require specialized skills and experience to develop and implement and should therefore it should be further explored with specialized workers. The team knows that SickKids may not have the in-house capabilities for all interventions, and the need for external resources was accounted for in the scaling of packages. Where financial constraints exist, this report can be used to demonstrate the importance and possibilities for improving the SickKids ED in an effort to secure funding and stakeholder buy-in. Operational feasibility and time requirements were considered in each package, resulting in a phased implementation approach. The low level package focuses on interventions that can be implemented in the current environment and existing ED structure. Medium and high packages require more extensive planning and consideration to ensure continuity of operations.
Limitations
The scope and focus of the project defined by the journey to the ED undoubtedly leave out many aspects of the wayfinding system that would ideally be considered if the entire hospital were to implement a wayfinding system overhaul.
1. A limitation to this proposal includes limited primary research on particular visit journeys, including the ambulance/paramedic journies, where observations were difficult to complete due to limited access.
2. Observations and spatial analysis were conducted specifically in the atrium, inside the ED and along paths typically taken to get to the ED. As a result, the team did not have specific intervention recommendations for all floor levels or departments of the hospital. However, the strategic principles proposed are transferable and scalable to fill this gap once similar primary and secondary research can be completed in order to understand the specific needs of each floor, department or clinic. Additionally, the spatial analysis would be required to understand the environmental impact on the current/future state and post-intervention.
3. Specific touchpoints that were considered but fell outside of our scope include navigational aids from TTC transit stations, inside the MaRs building and information support inside Toronto General hospital due to its connection through MaRs and the TTC. Further evaluation beyond the Sickkids boundaries could help improve additional points of tension along these journeys.
4. The project's scope limitations primarily focusing on spatial interventions, which means that there are aspects of this document that provide high-level information such as the extensive signage design and accessibility requirements for both legibility and access. Brief examples are provided to demonstrate the understanding that these specific elements would need to be further explored and integrated. Additional resources to guidelines are referenced.
5. The lack of patient or caregiver direct input into the wayfinding process presents a limitation to the study and our ability to fully understand from a first-person perspective how an emergency and stress levels impact navigation and user experience. Although, subject matter expert interviews and secondary research confirmed the validity of data collected from observation; the study was limited to observing patient/caregiver actions which present the observer’s subjective interpretation of their experience.
(Team-Work-Project)
Personal Role: My team (PatientOrientation:Wayfinding) and I have successfully managed to contribute in every step within this project design journey. This project stated during winter 2020, before COVID-19 was announced to be a pandemic in Canada and continued through the first wave. Therefore, everyone in the team was up to date, wanted to understand and work on this project. Specifically, I was able to work more on collecting data (primary and secondary research), reflect and analyze the data visually on maps and journeys, presentation design and content, prototyping the design example, and writing final reports.