Medical facilities in general, and hospitals in particular, are often seen as unfriendly places. Visits can be a cause of stress for patients and the general public because of the nature of the visits and the unfamiliarity of the setting. New staff, volunteers, and even existing staff who have been accustomed to their own areas, may not be comfortable navigating the facility, or the parts of it that are unfamiliar to them. During research by the NHS Estates in the U.K., 20 percent of patients and visitors said they were “very worried” or “quite worried” when they were at a healthcare site. Some complained about “getting angry because the directions weren’t clear.”

The anger and frustration is understandable when a person faces the labyrinthine routes common to hospitals that have a grown and expanded over time. The stress is great enough when you can speak the native language and can read the sometimes inadequte directional signs. But when you do not speak that language, it is much easier to feel isolated and to get lost, adding to the stress level.

In January 2003, JRC Design was tasked by Hablamos Juntos with developing recommendations for program standards for signage to best serve Limited English Proficiency (LEP) patients in a variety of healthcare settings. While the national program specifically mentions “Communication for Latinos,” JRC Design’s scope of work stated that, “the signage materials should not require literacy in order to be understood, and should be understandable to people regardless of their country of origin, primary language, education, socio-economic status, etc.”

The report showed that symbol signage is an effective means to communicate across language and cultures. However, the emphasis of existing, tested symbols has only been on transportation, recreation, and sports. And none of these systems were tested in the United States.

A collection of hospital symbols needed to be collected and tested per the standards developed by the International Organization for Standardization (ISO). This would require the use of facilities and significant expenditures of time and money.

Six Recommendations

The report outlined six steps that formed the basis for the symbol development project. They were:

1. Define a common terminology.
There is no standard for terminology, let alone, symbol usage, particularly when it comes to healthcare. One way to make this effective is to start with common nomenclature for room and department identity and symbol usage.

Telling family members to meet a post-surgical patient in the “PACU,” advising someone to come for an appointment in the “Imaging Department,” or telling a hospital patient that her room will be cleaned by “Environmental Services,” may leave patients and visitors scratching their heads. Part of the successful wayfinding is understanding the meaning of destination names and landmarks. Clear, widely understandable terminology will make it easier for patients and visitors to navigate in, and around, complex health facilities.

2. Develop a healthcare  symbol system and test it per ISO testing methods.
Based  upon the adopted common terminology,  have  a group  of designers, medical  professionals, and  lay people select existing designs  that are  reusable in a healthcare context, and  design  new symbols as needed, testing them for comprehensibility.

3. Develop a translation pool for the terms. 
Once  common terminology  (the referents) is decided upon,  it should be translated into as many languages as are likely to be encountered throughout  the United States. The U.S. Department  of Health and  Human Services’ Office of Minority Health (OMH) issued fourteen “Culturally and  Linguistically Appropriate Services” (CLAS) standards to aid LEP people  using the healthcare system. Standards seven and  eight are  the most applicable to signage:

 

 

The costs of translations  have  been  points of concern  for many people. In a report  on Health and  Human Services requirements  for cultural and  linguistic standards, the Texas Association  for Home Care, Inc., said:

Placing the burden on healthcare providers to obtain accu- rate translations of medical and/or legal documents is a very high standard.  Cost-effective resources may not be easily accessible to home care agencies and other healthcare providers to have materials accurately translated.

The common terminology, and  their related  symbols and  translations, will be combined to start an effective multi-language  “pool” of commonly used terminology, symbols, and  translations  for public use. Free access  to this common pool will make the use of symbol signs easier  to use and  more attractive  to medical facilities and designers alike. It is expected that over time, this pool should grow as new terms and  needs are encountered.

4. Develop user standards  for the symbols’ use. 
Implementation  standards for both signage and  uses of the termi- nology,  symbols, and  translations  should be developed. Standards will have  to be developed so that when symbols are used,  they will be used  in a manner appropriate for maximum effec- tiveness. The standards should show the adopted symbols, their English terminology  and  their translations,  examples of typical uses, do’s and  don’ts, and  an explanation of how the system works. There should also be examples of typical uses for translation  leaflets and maps,  and  how they are an effective tool of the entire multilingual symbol and  wayfinding  system. These standards should not define  a particular  signage system. The sign design  should be specific for each  individual  facility.

5. Educate medical and design professionals about the system. 
This combination  of terminology,  symbols,  and  translations  should be  announced to the various  organizations that can  most benefit  from and  use them: medical  administrators and  facilities man- agers  such as the American Hospital  Association;  graphic designers and wayfinding  experts  such as  members  of the Society of Environmental Graphic Design (SEGD), the American  Institute of Graphic Arts (AIGA); and  architects,  interior designers, and  plan- ners,  including members  of the American  Institute of Architects (AIA), the American Society of Interior Designers  (ASID), and  the American Planning Association  (APA). Having  these and  other related  groups involved will help to ensure the use and  success  of the program and  its adoption in other locations throughout the country.

6. Educate the public about the system. 
Once the new multilingual symbol system has been created, the public must be informed of its use. The final designs should be collected in booklet form, translated into the most popular languages, and distributed  to schools, adult centers, and organizations that cater  to communities with large  LEP populations. Educating  the public, both English-speaking  and  LEP, will play a key part in making the project  successful. Locally and nationally, communities should be told about  the implementation  of this new system. On the local level, opportunities  include community centers,  church groups, schools,  etc. Both locally and  nationally,  media  outlets—television, radio, and newspapers—should be contacted, and  may provide  free airtime or space through public service announcements. The more people  realize that such a system exists, the more they may request  that their local healthcare facilities adopt it. The attention to individual language groups should reflect well upon the local healthcare facilities.
The development of the above information,  including any maps, should be done  by graphic design  professionals, maintained by one department within the healthcare facility, and  used  by all other departments for the sake  of consistency  and  effectiveness.

What Happened

By March  2004,  Hablamos Juntos and  JRC Design signed  a pro- posal  to proceed with development of the symbols based upon the above recommendations. A design  team consisting  of six design  firms, including JRC Design,  was  organized. Wendy Olmstead of Ivy Tech Community College  was  retained to review and  compile the testing results. SEGD was  brought  in for on-site testing and  maintenance of the final product.

Both Hablamos Juntos and  SEGD had  technical  advisory committees. In mid-June, 2004, JRC Design sent a survey to the administrators of the ten grantee sites (Molina Healthcare, Inc., Long Beach,  CA; Inova Health System, Falls Church, VA; Temple University Health System, Philadelphia, PA; Central  Nebraska Area  Health Education Center,  Inc., Grand Island, NE; En Español,  Birmingham,  AL; Greenville  Hospital  System Foundation,  Inc., Greenville,  SC; School of Public Health–University of North Texas Health Science  Center,  Fort Worth,  TX; Regional  Medical  Center at Memphis,  Memphis,  TN; Choice Regional  Health Network,  Olympia,  WA; and  Neighborhood Health Plan of Rhode Island, Providence,  RI).

 

The instructions stated:

 

The surveys were sent back  to JRC Design at the end  of the first week of July. The results were  tallied and what emerged were  three tiers of referents:

1. Those that can be seen  from a vehicle (Emergency and  Ambulance Entrance)
2. Those that are services (Medical  Records,  Registration,  Billing Department, Waiting Room)
3. Those that are medical  terms (Cardiology, Mammography).

Thirty referents were selected  for symbol development. They were:

Medical  Records, Emergency,  Care  Staff Area, Laboratory,  Social Services, Billing Department, Pharmacy, Registration,  Ambulance Entrance,  Radiology,  Surgery, Pediatrics,  Intensive Care  Unit, Family Practice Clinic, Waiting Area,  Immunizations, Internal Medicine, OB Clinic, Cardiology, Diabetes,  Physical Therapy,  Chapel, OB/GYN, Oncology, Outpatient, Infectious Diseases, Mammography, Interpreter Services, Alcohol and  Drug Abuse, and  WIC (Women,  Infants, Children).

The design  team was  given this list and  asked  to develop  symbols based on the Department  of Transportation (DOT) “look” as a starting point.

• Wendy Olmstead provided  approximately 300 symbols that she had  collected from other symbol sets during  her study for her masters in graphic design.
• JRC Design also provided approximately one hundred  symbols they had  collected  from their research for the Hablamos Juntos report.

The design  team developed another 200 symbols. The team met in Paradise Valley, Arizona, on August 21,  2004 to review each other’s symbols and  to select five or six for each referent that would be tested.  At this meeting,  two of the referents were dropped from the list. These were Alcohol and  Drug Abuse and WIC (Women,  Infants, Children)—the former because it encompasses a variety of activities that would require  further analysis  and  the latter because it is a government program that does not need  an additional symbol.

Through a series of tests on October 2004, December  2004, January  2005, and  March  2005, the remaining  twenty-eight referents’ symbols were  accepted or rejected, revised,  or completely redesigned.

Field testing was done  at four sites throughout  the country: Sommerville, Massachusetts; Grand Island, Nebraska; San  Francisco, California;  and  Atlanta,  Georgia. These sites were  chosen  because they were  large  urban  areas, mid-sized cities, suburbs  of a large  city, or suburbs  of a small city.

Test results validated that the symbols helped  people, particularly  LEP people, to navigate the sites more quickly and with more confidence. With the completion of the final round  of tests, seventeen  symbols were found to have a comprehensibility  rating  of greater than 87 percent, meaning they bested  the criterion for acceptance per ISO standards. These symbols were  then redrawn to maintain  consistency to the overall look of the symbol set. The eleven remaining  symbols were  redesigned by the design team and  the technical  advisory  committees, using information from the tests to guide  the new designs  and  revisions.

What Didn’t Happen

As noted  above, testing of the symbols would be critical in helping to validate  which symbols should be used.  A testing method  developed by Harm Zwaga, researcher and  teacher  at the Psychological Laboratory  of Utrecht University in The Netherlands (who was  known for his work on information design,  wayfinding, and  signage systems), became our standard testing instrument.
Ideally, for these symbols to be truly “universal” in acceptance, they should be tested in various countries using indigenous populations. There was no time, money, or facilities to do that. Testing people  who are  LEP is, at best, an approximation. It is not known how much assimilation with American culture each  participant had,  although  it could be argued that in many other countries, the American culture is difficult to avoid.

Timing also became a concern  as the last paper tests were  being conducted at the same  time the field tests started.  Better coordination would have  allowed  more testing of the eleven symbols that tested equal  to, or lower than,  87  percent.

A fourth round of testing would also have been  useful. As noted above, the seventeen  top symbols are being  redrawn. It would be helpful to find out if that step affects their test scores.  It would also have been good  to do another  round of tests for the eleven redesigned symbols.

How We Decided on Our Process

Having  worked  on several  hospital  and  medical  facility projects, we were  well aware of the lack of symbols available for healthcare. When  this project  came  to us, we were  able  to convey to Hablamos Juntos our enthusiasm  and  the great  potential  this project  had  to benefit the population. During our research, we learned about  the ISO testing methods. Those methods  seemed  comprehensive and would  serve to validate the symbols ultimately used  in the set. Our  research also  led us to Wendy Olmstead’s masters  thesis,  Comprehensibility Estimates of Symbols for Public Information Signs in Health Care Facilities. The information  proved  invaluable  and allowed  us to create  an even  better  informed  report.  We  knew there would  be  several referents  that would defy immediate  comprehension—and thus test poorly—no  matter  what  we did,  and  that education would be  the key to the overall success  of the project.  We  were  expecting about 50  percent  success.  Instead  we achieved nearly  61  percent  success with all the symbols.

 

Test  Materials

The original  tests consisted of a five- or six-spoked wheel approximately seven inches in diameter. At the center of the wheel was another circle two inches in diameter. This circle had  the definition of the referent.  Each spoke  contained a white symbol within a black, one-and-five-sixteenths-inch square. At the top of each sheet were the instructions:

For each healthcare  symbol shown,  please estimate  the percent- age (%) of the United States population  you think will understand what  it means.  100% means  everyone, and 0% means no one.

Each person  was given a test form of twenty-nine  pages, one for each referent  and a cover instruction page. The tests were available in English and  Spanish,  and  translators were available for other language groups. The tests were  administered by the ten grantee sites. Each round  was  to have  ten participants: two English speaking, two Spanish  speaking, three  speaking Asian languages, and  three  speaking European languages.

Field testing included placing symbols over existing signs, directory mockups using symbols and  text, and  matching tests. Participants  were asked  to navigate a trail using the existing sign system only, a paper map with symbols to match the mockups,  a paper with only the symbols, and  a combination of all three.  They were timed as they walked  each path.

The final set of symbols may be downloaded at either www.hablamosjuntos.org or http://www.segd.org/resources/symbols.html.

 

The Future of the Symbols

The concept  of a set of symbols specific to healthcare has met with great  interest from both the design  and medical  fields. The set is cohe- sive in look, and  as the ancillary  materials  are  written, the set should be comprehensive in scope.

It is not a complete  set, however.  We  recognize about  fifteen to twenty additional referents that may be useful to add  in the future. SEGD is working with several  universities to assist in the research and testing needed for this next step.

For the future symbols, testing is invaluable. It helps to eliminate bad symbols and  emphasizes the good  symbols. But “bad” and “good” have  different meanings in this case.  They represent  whether  a symbol is comprehensible and  meaningful  to the general public.  We found that the public tends to respond to more information in a symbol, particularly  if there is any ambiguity  within the design.

For any new symbols, several  steps are  recommended:

1. User research. Prior to any drawing, the general public should be surveyed,  asking  their opinions  as to what a referent should look like.
2. Broader  pool of designers. The designers seemed  to lock on to certain concepts  early in the process. Any revisions were often minor. Changing designers after each  round of testing may open  up the design  options.
3. Additional  testing for symbols that tested  equal  to, or lower than, 87  percent.  Matching  tests may allow for additional acceptance of symbols testing below  the baseline.
   

Topics: Graphics, Healthcare, Plain Language
Published in: March, 2006 in Usability for the Planet

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