Wayfinding may be considered by some as one of the major causes of stress during one's healthcare experience. Finding a place to park, getting to the main entrance, figuring out where a department or office is, and then worrying about being late for an appointment are all issues that many patients face.

Poor wayfinding adds to the stress and frustration, and the quality of the wayfinding experience can affect the rest of the patient's visit and, in turn, hospital satisfaction scores. During my experience working in a large medical complex, I remember it taking almost a month before I felt like I knew where I was going when looking for departments across the campus. White corridors that seemed to loop around in circles with little differentiation between floors did not help the situation. Giving clear directions to people who were lost in the building was almost impossible.

As designers, we can control many of these environmental factors to improve that experience. With healthcare facilities being some of the most complex and often-changing environments, there are several options that we should consider in addition to evidence-based design measures that provide easier navigation and a less stressful experience.

Signage options

Signage has been one of the more traditional ways of approaching the concept of wayfinding. However, it should not be used as the only solution. In the healthcare environment, we are dealing with a wide range of demographics in literary levels, languages spoken, and visual acuity, to name a few. Our selection of signage needs to be well thought out. Everything from the size, contrast level, and color of the text to the location of the signage should be evaluated. I once saw a piece of signage in a hospital that not only had an almost illegible font, but was on a patterned background. Even with 20/20 vision, I could not pick up on what exactly the sign said.

As much as we would like to be creative and artistic, we have to be mindful of the purpose and the importance of signage as well as ADA code requirements. The wording on a piece of signage should be thoughtfully examined and discussed with the integrated project team. If a nurse often directs a patient to get an “X-ray,” yet the signage communicates “diagnostic imaging” or “radiology,” then some patients may have an issue finding the destination. The amount of text on the signage is also important. It shouldn't be too cluttered and should minimize confusion.

Text signage is not the only signage to be considered; using symbols is also common and logical in these environments. Symbols used to classify various departments or patient towers could be designed specifically for the organization. With the development of universal symbols in healthcare environments, implementation of some of those icons could be considered, especially in environments frequently visited by multilingual patients. A less frequently used alternative is providing the distance to a specified destination on the signage. For example, a sign may state “Cafeteria, 100 feet” and show an arrow directing right. This type of sign helps frail patients judge if they are able to walk the entire distance to their destination or if they will need wheelchair assistance.

The use of color and landmarks

Color also is a design element that we can use throughout the wayfinding process. By color-coding elements on varying floors or by departments, we can reduce confusion in multistory buildings. Especially in buildings where floor layouts are similar on each level, color can make a big difference. One example may be to provide color at the stair and elevator landings with the corresponding floor number and then extend the color by providing it on that floor's signage, accent floor tiles, or accent walls. This subtle solution can play a big part in the patient's ability to remember which floor they need to be on. The plan in Figure 1 portrays which colors will be used as accent colors in each department area.

Landmarks or distinctive pieces of artwork can also provide visual clues in wayfinding, or aid in backtracking out of a building. For example, including a sculpture at a corridor intersection is one option. Nodes, where multiple corridors come together, are good areas to include landmark objects. Providing a well-lit area with a distinct floor pattern, clear signage, and memorable artwork are all effective ways to plan a node. Figure 2 shows a tiled mural wall as a landmark feature to direct the patient to the reception desk.

You are here

Although the “You are here” signage maps in major intersections are helpful, how effective are they? I usually spend a good amount of time trying to figure out how I'm oriented in relation to the map. If those maps are a proposed solution, making sure they are oriented in the direction of travel is highly important.

With the evolution of GPS and radio frequency identification technology, an interesting alternative could be a programmed tablet computer that each patient is equipped with upon entering the facility. Through coordination with IT and other professionals, a user-friendly interface could be developed that directs patients via voice and visual commands as to where to turn to arrive at their appointment location. The tablet could then double as a patient education device during the waiting and examination process. Security, return, and cost would all be issues to work out, but having an interactive map could prove to be more effective than a paper map or signs on the wall.

Other proposed ideas might be to provide an application that patients can use on their smart phones or iPads. However, one thing to think about with technology is the patient demographic. Although many people are tech-savvy thanks to the evolvement of computers, there is still a learning curve and some patients may not be familiar with how to use the devices effectively. In this day and age, it's also important to provide maps on the healthcare organization's Web site since many patients will do research before their visit.

The “Ritz Handoff” system, based on the hospitality service of Ritz Carlton hotels, is another idea to consider. Implemented in one of The Center for Health Design's Pebble Projects, the system evaluates what would make the most exceptional customer service experience for the patient. One of the effective forms of customer service in this methodology is to break away from the traditional reception desk by providing “perches.” With roving greeters, patients can be quickly greeted by an employee and directed to where they need to be as soon as they step foot in the lobby. With many nurses taking the time to escort patients from point A to point B, a separate set of staff for these situations would be worth considering to reduce the amount of time the nurse spends away from the bedside. When a patient is approached by a smiling, helpful staff member as soon as he or she walks in the door, more than likely the patient's stress will go down and overall satisfaction will go up.

Developing the floor plan

The floor plan and overall circulation path is perhaps the most important component to consider when discussing wayfinding. After all, the fact that we have to plan for wayfinding tells us just how complex our environments really are. Although a degree of complexity is inevitable due to the wide range of healthcare needs and departments, the more simple the floor plan the better. This simplicity can be executed by having main arteries of circulation, curved walls that subtly direct patients, and perpendicular angles at turning points. Access to outside views through windows in the circulation path also is important for a patient to maintain a sense of direction. I'm sure we can all rel
ate to the confusion that windowless walls and long winding corridors can create, and how easy it is to lose your sense of direction in those situations.

Some questions that we should contemplate include: How does the floor plan respond to the fact that humans have a natural inclination to turn right? With the hospital environment being one that is constantly evolving, how can we make the transitions and departmental moves easier on the visiting occupants? When adding additions to an existing building, is there a smooth transition between the old and the new? The degree of clarity of the floor plan will also aid in the question of how one will be verbally directed from point A to point B. Giving directions containing a series of left and right turns will only confuse the patient and subsequently waste staff time. However, describing distinct landmarks in the directions may improve the patient's retention of the directions. The way we develop our design solutions will have a major impact on these situations.

Through the principle of unity, it is important that all wayfinding materials, from signage to maps, are designed consistently. Making sure that text and terms, symbols, colors, and other elements are persistently portrayed in the same manner on signage, paper handouts, the organization's Web site, and other materials is important and will minimize patient confusion. Hospital employees should also be knowledgeable of the materials so that verbal directions are consistent as well.

Incorporating evidence-based design

Poor wayfinding can not only lead to low patient satisfaction and stress, but it can also lead to wasted staff time and money. Several ideas have been discussed about how wayfinding can be improved, but how can a hospital tailor the wayfinding plan to their specific needs? By using the process of evidence-based design, the project team can study which methods would be most effective for the hospital's specific situation through existing research or by creating new research.

Several studies have found that one type of wayfinding tool may lead a person to finding the destination faster than other tools-the Ulrich, et.al. white paper, for example, cites other studies that found signs to be faster than maps. By evaluating those studies, or conducting new ones, an organization can figure out where to focus its wayfinding efforts. A new research plan could also be created with the help of an interdisciplinary project team that involves patients and families who study what is more effective to them and what causes them stress during the wayfinding experience. Another research study could be done on traffic patterns and the most frequented paths by patients. For example, if a study finds that 30% of patients are entering the building from a certain parking garage and their destination is the emergency department, is the circulation path and signage easy to navigate? Evidence-based design can help answer many of these questions and improve outcomes and return-on-investment when executed properly.

IMAGES COURTESY OF CAROLINE LEEMIS

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Sources

1. Berger C. Universal Symbols in Healthcare Workbook. Available online at: http://www.hablamosjuntos.org/signage/PDF/Best%20Practices-FINALDec05.pdf
2. Cama R. Evidence-Based Healthcare Design. New Jersey:John Wiley & Sons, 2009.
3. DeGeeter M. ASID: Wayfinding in Healthcare. Posted on Healthcare Design Magazine, Blogs at healthcaredesignmagazine.com/blog, 2009, September 17)
4. Malkin J. A Visual Reference for Evidence-Based Design. California:The Center for Health Design, 2008.
5. Ulrich R., Zimring C., Zhu X., DuBose J., Seo H-B., Choi Y-S., Quan X., Joseph A. A Review of the Research Literature on Evidence-Based Healthcare Design. Health Environments Research and Design (HERD) Journal, 1(3). Available online at: http://store.healthdesign.org/a-review-of-the-research-literature-on-evidence-based-healthcare-design.html

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Healthcare Design 2010 December;10(12):14-19