hcd_2013_way-finding study

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Lost in the Hospital…What Environmental Cues Do We Seek?

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Presenters

Tom Harvey FAIA, MPH, FACHA, LEEP AP Vice President/Partner, HKS Architects President, Center for Advanced Design Research & Evaluation

Debajyoti Pati, PHD, FIIA, LEED AP Rockwell Endowment Professor, Texas Tech University Director Emeritus, Center for Advanced Design Research & Evaluation

Phyllis Kaplan Senior Health Facilities Architect, U.S. Department of Defense Defense Health Agency (DHA)

Portfolio Planning and Management Division

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Acknowledgements

Contributing Organizations

Military Health System

Texas Health Resources (IRB)

Texas Health Presbyterian Hospital Dallas

Study Contributors

Douglas Willis, RN, BSN, Safety Manager, THPHD

Sipra Pati, MA, Research Coordinator, HKS

Adeleh Nejati, PhD Candidate, TAMU

Shireen Kanakri, PhD Candidate, TAMU

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Learning Objectives

1. Identify the range of environmental

information sought by visitors during

navigation in hospitals.

2. Identify the types of physical design

elements used as cognitive anchors in

direction-giving behavior.

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Agenda

The Wayfinding Problem

What We Know and Don’t Know

Study Background

Study Question

Method

Findings

Implications

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Wayfinding…

An All Too Frequent Challenge

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Affects patients and visitors • Impacts satisfaction

• Induced stress

• Physiological well-being

• Psychological well-being

Affects staff• Compromises optimal use of staff time

• Communication challenges

• Challenge to float or agency staff

• May impact efficiency of care delivery

• May impact care safety

A Forethought OF Design

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Wayfinding…

What We Know and Don’t Know

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The “Cognitive Map”

Known strategies:

• Survey knowledge

• Route knowledge

Image Credit: http://groups.ischool.berkeley.edu/mentalmaps/

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Mini Spatial Representations

“Adult human knowledge about

their macro-environment are

mini-spatial representations

with high interconnectivity…”

Image Credit:

http://www.lifesreplay.com/journal/2011/11/29/yuya-

takeda-falling-apart-complex-cities.html

The Development of Spatial Representations of

Large-Scale Environments Siegel and White, 1975.

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Most documented studies are at the urban scale

Kevin Lynch,1975. Image of the City. Components of

mental maps

o Path

o Edge

o District

o Nodes

o Landmark

Insufficient Focus on Internal Need

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What We Know

Theory of Perception - Cognition

o Environmental Complexity

o Cognitive Filters

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Five Factors in

Wayfinding

Carpman and Grant, 1993

• Knowing where you are

• Knowing your destination

• Knowing the best route

• Recognizing the destination

upon arrival

• Finding the way back

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What We Don’t Know

1. Are these theories valid in interior

environments?

2. What information do people seek when they

navigate for the first time in an unfamiliar

environment?

• Wayfinding in places not frequently visited.

• Navigating the first time vs. subsequent times – the difference?

• What features are used to begin forming the cognitive map?

• Where is the start point of the action/travel plan?

• What features are used during execution of travel?

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Current

Designer’s Tools

Designers use a wide

array of strategies to

optimize navigation:

• Signs

• Maps

• Artwork

• Landmark

• Color

• Spatial configuration

• Alpha-numerical labels

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Tools of the

Navigator

Which strategies are used

during wayfinding?

o Understanding current location

o Knowing destination

o Developing route choice

o Realizing arrival at destination

o Findings one’s way back

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Wayfinding…

Study Background

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MHS FIRM

U.S. Department of Defense

Facility Innovation & Research Model (FIRM)

• Established an MHS FIRM Research Framework

• Tested through multiple Validation Studies

Identifying Elements of the Healthcare

Environment that Contribute to Wayfinding

U.S. Department of Defense Military Health System

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Wayfinding…

Study Question

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Question 1

What aspects of the

physical, social, and

organizational

environment aid in

wayfinding decision

making?

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Question 2

What types of

information are being

sought by visitors as

they navigate in

healthcare facilities?

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Question 3

What role do design of

interior environmental

cues play in the

wayfinding process?

• Color

• Art

• Visible Landmarks

• Maps

• Interactive Kiosks

• Visual Signage

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WAYFINDING…

Study Method

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Study Setting

Texas Health Presbyterian

Hospital Dallas• Main Building

• Hamon Tower

• Professional Building 1

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Campus

HAMON TOWER

ADDITION

MAIN TOWER

BUILDING

PROFESSIONAL

BUILDING 1

OTHER

MOBs

WOMEN’S

CENTER

BEHAVIORAL HEALTH

BUILDING

Public Site

Entrances (2)

Staff / ED

Entrance

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Vertical Circulation Elements

HAMON TOWER

ADDITION

MAIN TOWER

BUILDING

PROFESSIONAL

BUILDING 1

WOMEN’S

CENTER

BEHAVIORAL HEALTH

BUILDING

PP

P

S

Esc

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Horizontal Circulation Elements

HAMON TOWER

ADDITION

MAIN TOWER

BUILDING

PROFESSIONAL

BUILDING 1

WOMEN’S

CENTER

BEHAVIORAL HEALTH

BUILDING

PP

P

S

Esc

cP P

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Destinations

External

Starting

Point 1

Parking

Lot

2

Patient

Room

4

Cafeteria

5

Imaging

Check-in

6

Chapel

7

Surgery

Waiting

8Admission

9

Parking

Lot

12

Interv.

Center

11

Prof.

Building

10

Main

Lobby

3

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Patient / Visitor Direction-seeking

Age groups – 5 decades starting at 20

Gender – 50% male / 50% female

Recruitment criteria…

• Never visited this hospital site

• No architects or interior designers

• No visual impairment

Subjects

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Subjects

Employee Direction-giving

Any full-time employee of the Hospital

Recruitment:

• Visual identification by presence of ID card.

• Staff approached at each of the

destinations on the patient/ visitor

routes

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Data Types and Instruments

Visitor• Verbal protocol

• Audio recording

• Route maps

• Photographs

• Questionnaire

Employee• Verbal directions

• Audio recording

Participants articulated/

recorded their

decision-making thoughts...

I-Pad Tracking of Routes

Features and Signs Observed

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Wayfinding…

Preliminary Findings

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Understanding where one is (where am I?)Two types of ‘where I am’ situations

• Start point – Travel plan

• En route – Travel

execution

• Continuous assessment

Understanding where is the destination (where to go?)

• Especially where it is in relation to

where I am

Two Broad Aspects to Wayfinding

1

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Understanding how to go to the destination

from where one is (at a point of time)• Is there a way to predict that I am on the right path?

o Circulation system assessment (elevators, hallways…)

o Continuous ‘where I am’ assessment

• Is there a way to predict what the destination looks like?

(More importantly) how to get back to where

one is (was) – this is critical, since among all

the ‘where one is’, people seem to select one

or more former locations as anchor points.

Two Broad Aspects to Wayfinding

2

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Where am I?

Where to go?

How to go there?

People seem to rely entirely on

• Maps

• Signs

Elements Supporting Wayfinding

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Maps• Expectations to find the

exact name on the map

• Main focus on:

o Paths

o Circulation

o Districts

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Signs:

• Labeling systems/ nomenclature

• Numbering systems

• Directional signs (with arrows)

• Chronology/ Order of information

• Patterns

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Do other elements

contribute?

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Other Cues: Logical

Clustering of Functions Space Planning

• Café must be close to

lobby

• Admissions would be

near the entrance/ lobby

• Children’s play area

indicates waiting area

close by.


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Other Cues: Furniture

Arrangement Furnishings

• If there is seating, it must

be a waiting area

• One subject indicated that

comfortable couches

indicated a waiting area


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Logical pairing of interior

elements Interior Architecture

• Admissions could mean ‘windows’/

windows indicated that it could be

admissions


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Structural Elements Structure

• deep columns implied

elevator bank


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Architectural Features and

Visual Access Architecture

• External view of an area – looking

at its width the subject inferred that

it did not have the capacity to hold

a waiting area or that they were

headed in the right direction

• Visual access of spaces via multi-

level atrium


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What about all the other design

elements we incorporate?

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What Role Do Other Features Play?

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Developing familiarity

Develop mental map • Where people made mistakes

• Funny or odd sounding names

Like while one is hiking in the

wilderness:• People use any natural element

as markers

• Or create markers (leave pebbles

on ones path)


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Other Design Elements Help Serve As

Familiarity Markers


• Information desks/ counters (manned or not)

• Vertical circulation (especially when visually unique such as

escalators

• Artwork/ sculptures (people did not focus on the content/

subject of the landmark)

• Views to exterior and exterior elements (exterior signs and

labels, visible from inside, served important function)

All of these can be termed as landmarks.

Every landmark is a pebble.

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Implications

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Nomenclature and Numbering System

• Represents the initiation of the

cognitive process

• Even before people look for signs

and maps

Key Concept 1: What’s in a Name?

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Anchor Point Use and Characteristics• A place close to an exterior entrance and vertical circulation:

o Doesn’t need to be the entrance people used to enter the facility

• Multiple activities

• Presence of people

• (Expected) presence of maps and directional signs

• Even if this anchor point had not been very effective in offering

adequate help in locating their destinations, subjects still sought to

return to these anchor points to orient themselves.

o Home base.

o Where everything is

o Where I feel safe

o That’s where I get help

Key Concept 2: The Mother Ship

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Familiarity, Familiarity, Familiarity (Think of the Jungle)

People tend to immediately start working on developing familiarity of

“nodes”, “edges” along a path

• With directional signs, maps, plausible location of maps,

information boards …

• Higher the complexity (types of activities, people, artwork)

easier the development of familiarity

Key Concept 3: Fight or Flight

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Path (streets, sidewalks, trails, other channels in which people travel)

o Where am I; where am I going (maps, directional signs…)

Edge (perceived boundaries such as walls, buildings, and shorelines)

o Hallway edge functions (familiarity)

District (large sections of the facility distinguished by some identity)

o Where am I; where am I going (maps, directional signs…)

Node (focal points, intersections or loci)

o BOTH (MOST IMPORTANT)

Landmark (readily identifiable objects which serve as external reference points)

o Familiarity

Key Concept 4: Cognitive Markers

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Thank You!

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Thank you for your attention…

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hcd_2013_way-finding study

Design

hcdcon wayfinding

hcdcon acknowledgements

hcdcon lost

hcdcon agenda

hcdcon learning objectives

cognitive map

wayfinding carpman

wayfinding problem