Question how do you evaluate user satisfaction

Building users are frequently categorised as clients (in the sense of being the building owner) and, this is often the case. But in the health sector building users consist of a more diverse group of people. It is immediately apparent that effective consultation with future patients will be more difficult to achieve during the design process than with a group of GPs even if they are the tenants of a building which is being procured by others. This poses considerable difficulties for the architect because a successful building must be a response to the needs of the future users of a building, and the design must be informed and influenced by those considerations. As the new NHS Plan makes clear 'Too many patients feel talked at rather than listened to' (NHS, 2000).

The architect's task is further compounded by the need for future buildings to accommodate the rapidly changing treatment regimes. These are a consequence of the explosive rate which information is becoming available to all together with the shift to a patient-centred approach to primary care. Therefore, historical evaluations of existing buildings are likely to be of limited value and great leaps of imagination will be required to design the new buildings from which these new services will be administered. Perhaps it will take time for

Figure 4.7 Wideopen Medical Centre, Newcastle upon Tyne: external view. Architect: Geoffrey Purves Partnership (also in colour section)
Futur Medical Center

WIDEOPEN MEDICAL CENTRE Figure 4.8 Wideopen Medical Centre: ground floor plan. Architect: Geoffrey Purves Partnership patients to understand the new power within their grasp to influence the shape of future facilities. However the influences of supply and demand in the market economy will inevitably challenge the providers of buildings to meet the new requirements.

The following two examples illustrate short participant observation exercises conducted in surgeries designed to the standards of the 'Red Book' during the 1990s.

A short participant observation project conducted at the Gosforth Memorial Medical Centre, Newcastle upon Tyne - an examination of how the waiting room functions

Background

As architect for many GP surgeries (both new and refurbishment projects) I thought that it would be interesting to examine the operation of a waiting room during a typical midweek morning surgery session. My architectural practice (the Geoffrey Purves Partnership) carried out improvements to the Gosforth Memorial Medical Centre, Church Road, Gos-forth, Newcastle upon Tyne in 1992/93 for Doctors Ian and Sandra Winterton, a two-doctor (husband and wife) practice who had increased their number of patients and required additional space to improve their facilities. A central requirement of the alteration works was to improve the waiting area, and create a more welcoming and pleasant entrance to the building. This involved forming a new footpath to the street, building a new canopy, and organising an obvious place for patients to enter the building, giving shelter from the elements, followed by a pram space, leading into a reception area. The reception desk is immediately obvious, and three sub-waiting areas are immediately adjacent to the reception desk offering a choice to patients. Two are used by patients waiting to see a doctor and one (on the left when entering the building) is used by patients waiting for a treatment clinic.

Preparation for observation period

Because I have worked with the doctors for several years, and I am one of their patients, there was no difficulty in discussing

Figure 4.9 Gosforth Memorial Centre, Newcastle upon Tyne: reception/waiting area as built. Architect: Geoffrey Purves Partnership (also in colour section)
Figure 4.10 Gosforth Memorial Health Centre, Newcastle upon Tyne: ground floor plan. Architect: Geoffrey Purves Partnership

my proposed observation of the operation of the waiting room. They were happy to allow me to sit 'as a patient whose turn never arrived'! Before undertaking the observation period I also arranged to have a short discussion with the administrative staff and completed the questionnaire (which forms part of the Environments for Quality Care document). This is offered as a checklist to GPs who are considering improving their facilities as part of the booklet of exemplar projects published by NHS Estates (1994).

I am pleased to say that the surgery scored highly on the questionnaire, and the staff were generally very happy with the improvements which had occurred following the building works. It was thought to be 'much better', and that privacy was improved. Criticisms that were raised included a comment that '... the bell on the reception desk was not used very often, and some patients on arrival seemed a little reluctant to draw attention to themselves by using it'. Other criticisms that were mentioned included an observation that the pram space at the entrance was larger than necessary, and that the signs for the doctors' surgeries and the patients' toilets could have been clearer.

Wheelchair access is difficult to one of the doctor's surgeries (Dr Winterton) and it was observed that there is no lower section of the reception desk to enable a wheelchair user to have an easy line of sight to reception staff behind the reception desk. There is no separate children's play area, although children's toys were provided and there were mixed views as to whether a separate play space would have been preferable. Generally, I gained the impression that the staff were well disposed towards the building, and were a friend ly and cheerful group who enjoyed their work with a smile. One comment made by the receptionists about the paintings hung in the reception area was 'why do we need pictures when they have us'!

Participant observation

All patient names have been changed to ensure confidentiality. I arrived as a prospective patient at 8.45am on Tuesday 10 March 1998 and announced my pre-arranged arrival at reception. I took a seat in the waiting area and quietly observed the proceedings for the next 45 minutes.

08.45 Two sub-waiting areas - some patients waiting already - father and son - reading from book -no particular children's play space - child asks

- What is crooked? - father replies - not particularly straight - children's books available neatly displayed with selection of magazines on low table.

08.50 Single women arrived - ringing bell for attention

- some noise - warm/bright atmosphere - outside views possible to look at the weather. Small groups - two parents + children (five in total).

'Alistair don't do that, pick them up' - partly overhead conversation.

Small table - generally quiet/relaxed - a wall display unit for pamphlets - copies of practice pamphlets freely available from the reception counter - a larger report, also on the reception desk gave more details of the practice philosophy, including brief details of the doctor's qualifications and experience (including specialisms).

08.55 Two women arrived - one filling in form/one quietly reading.

Child left on his own reading a book while father called to surgery and mother waits in adjoining waiting area - on fathers return child asks -What's happening? - father replies - I've just got my note - family group left, father, mother and son.

One woman, form now completed rang bell for attention - then left.

Very quiet - two women waiting.

08.57 Mother and child arrived - sat in other sub-waiting area. No discussion between patients - both reading magazines - body language - independent/no eye contact - relationships as if in a coffee shop.

09.00 Male patient arrived and also Dr Winterton through main entrance. Male patient waited at reception - then mother and child (son) arrived - Male patient appeared to know one of the women.

Small talk - not feeling well. General chit-chat about winter bugs - moved closer together to engage in more conversation. Mother reading to son in other sub-waiting area. Conversation in hushed tones. would some background music have helped to provide 'white noise'? - overheard conversation about teaching/schools/staff problems - again, thinking of body language - similarities to friends meeting in a hotel lounge.

09.05 Grandfather (I assume) arrives with child in pushchair.

Call for James Fisher (son/small boy). Older woman picks up prescription/examines it and rings bell for attention. Man has heavy cold/blowing his nose, etc. Some sighing (minor irritation by delay?) - from single women who is still waiting - now six people waiting (four adults and grandfather and son). Miss ? called for Sandra Winterton at 9.11.

09.12 Young woman arrives at reception, asks for directions to clinic next door - and leaves. Call for David Leigh: 'he's just got a bag full that he's dishing out' - an aside by David Leigh to his friend as he leaves (referring to his quick consultation and receipt of a prescription) - next patient arrives/Sandra West - picks up magazine to read - grandfather and child called to surgery. Now three patients waiting.

09.17 Now two women at reception - aural privacy could be a problem - can overhear some conversation.

Mrs Gerrard called to doctor. Patient at counter has discussion and leaves. Man arrives (55ish?) and mother and child. 09.20 Mother and child arrives - child lifted to ring bell (very loudly) - picks up prescription or form and sit in front waiting area. Generally no crush/adequate space/relaxed, comfortable feeling - planting/views out possible to street and internal courtyard. Child making funny faces through glass from one waiting area to another - enjoying this! Sub-waiting one or two mothers + children. Sub-waiting two men.

Next patient arrives at counter - asks for prescription and leaves. Cyril Taylor called to surgery. 09.25 Next woman patient arrives - any chance of an appointment today?

Engages in conversation with two reception staff

- chatting animatedly.

Older man now slightly restless/doesn't look well

- looks absent-mindedly at a couple of magazines - full of cold or flu?

Next woman patient arrives at reception. Mother and child. Mr Telfer called.

Matthew Newton called - doesn't appear to be present in waiting areas. 09.30 Woman still chatting at reception.

Sub-waiting on left of entrance not being used (because no clinic is being held).

Conclusions

I arrived at the surgery intending to find appropriate moments to engage in conversation with some of the patients. However, in the event, there never seemed to be the right moment to naturally engage in conversation. Had I done so, the advantages of observing as if 'a fly on the wall' would have been lost and the exercise would have been changed into a user-questionnaire type relationship. I concluded that the advantages of merely observing outweighed the potential disadvantages of disturbing natural behaviour.

Having been involved in the design of the building, I arrived with a number of pre-conceptions as to how the space would function. After this short exercise I have changed my opinion. In general, the spatial relationships between approaching the building, entering the main doors, passing the pram parking space, registering at reception and waiting until called by a doctor functioned more smoothly and quietly than I expected. The relatively sophisticated but relaxed manner slightly surprised me. I was anticipating a space which would be rather more chaotic, more noisy, and less structured than was the case during my visit. I am unsure of the reasons for this atmosphere - is it a result of good architectural design or efficient management of the practice? Perhaps it is a combination of both.

New Reception Area Sketch
Figure 4.11 Gosforth Memorial Health Centre, Newcastle upon Tyne: sketch proposals for new reception/waiting area. Architect Geoffrey Purves Partnership

Although a number of young children came into the building to visit a doctor they made no undue noise, and there was no crying whatsoever. Assuming that the children were not well, or even if they were well and coming for say an inoculation, there was no perceivable level of stress. Quite the reverse, in fact, with a relaxed atmosphere and several parents quietly reading to the children. Another parent accompanied an inquisitive child around the sub-waiting areas in a cheerful and contented manner.

The waiting areas were less crushed than I expected, with room for comfortable spacing between waiting patients, although I was assured by the reception staff that it was a typical morning clinic. Patients treated the building with respect, appeared to be comfortable in pleasant surroundings, and quietly waited until called by loudspeaker to go to the doctor's surgery. Shelving units adjacent to the reception counter offered a supply of health leaflets and a brochure about the practice. As you would expect, patients tended to be either young adults accompanying children or older people.

This practice serves approximately 6000 patients, and after the observation session I asked the reception staff a number of further questions. The pictures which were hung on display were for sale and I asked if any sales were achieved. I was advised that pictures were sold from the waiting room and that the doctors periodically received a commission cheque which was donated to the Yellow Brick Road Children's Cancer Charity. The problems highlighted earlier with regard to limitations on disabled access was not a serious problem because usually a disabled person was accompanied by another able-bodied person. Although snippets of conversation were occasionally overheard a separate interview room is available and I was assured that on occasions this was used when individual patients requested a private discussion or where patients became distressed. An example given was when a patient was referred immediately to a hospital by one of the doctors which could give cause for considerable dis tress. I asked if they had considered playing background music and although this had been considered it had been decided as inappropriate.

My overall impression was that the space performed more successfully than I had anticipated. Although some relatively minor criticisms were raised (as already mentioned) one of the reception staff joked with me that on more than one occasion a patient had arrived and asked to book a room -the favourable comparison of the entrance area to a hotel foyer was regarded as a compliment.

A short participant observation project conducted at the West Road Surgery, Newcastle upon Tyne - an examination of how the waiting room functions

Background

Following a similar exercise that I carried out at the Gosforth Memorial Medical Centre I visited the West Road Surgery to observe a typical Friday morning surgery session on 19 June 1998. I had previously discussed this exercise with Dr Tony Francis who was happy for me to observe the way their waiting room functioned.

The Geoffrey Purves Partnership had acted as architects for a refurbishment and extension of this medical practice which is located in a tough inner-city environment (designed and constructed between November 1995 and May 1997). It is located on a corner site in a parade of shops on the West Road, Newcastle upon Tyne within the Benwell area of the city, renowned as having a number of serious social problems such as high rates of unemployment, and crime. The existing building had presented a fortress mentality with the premises guarded by a high brick wall perimeter fence topped with barbed wire.

Figure 4.12 West Road Surgery, Newcastle: external view. Architect: Geoffrey Purves Partnership (also in colour section)

Our instructions were to increase space, improve the facilities, and re-organise the entrance, which was an unsupervised lobby opening off the main shopping street. This space was frequently trespassed by unruly local school children during their lunch breaks and was a constant source of management difficulties to the practice manager and doctors.

As at the Gosforth Memorial Medical Centre I sat in the waiting room as if 'a fly on the wall' and observed the behaviour of patients and reception staff. The same questionnaire used by the Gosforth Memorial Medical Centre which forms part of the document Environments for Quality Care (NHS Estates, 1994) had also been previously completed by Dr Francis which records a high level of satisfaction with the refurbished building.

Participant observation

All patient names have been changed to ensure confidentiality.

08.30 Busy entrance - introductions to Mrs Muriel Cowans and Dr Tony Francis - somebody has locked the front door - telephone ringing continuously in reception - five people waiting -mother and child (playing noisily with toys) -phone stops ringing (unanswered). Mother, daughter and child arrive at reception - phone starts ringing again. 'if you want to wait until a doctor is free' - phones continuing to ring - 'doctors surgery - a visit?' 08.35 Another patient (women) arrives - asks for patient toilet.

'Ten to ten on Monday (09.50)' - phone conversation overheard 'When would you like to come, this morning or this afternoon?' '5.30 with Dr Heardman'. Intrusive ringing of phones. Patients' attention seems to be held by the activity behind the reception desk. Magazines piled untidily on small table. 08.40 Patient arrives at reception desk to see Dr Dixon

- directed to first floor waiting room.

Child in pram starts to cry. Mother takes small son to the toilet. First patient leaves.

Sheila Moore - misunderstanding at reception

- walks briskly to desk - 'I'm waiting' - sotto voce

- 'O God!' - paces into consulting room with child.

08.45 Next patient called.

One patient now remaining in waiting room. Mother and child leave consulting room and leave. Mrs Chapman - arrives at reception - known to staff who chat to her - 'it all happens at half past eight - that's it for the minute' - discussion 9.07

behind reception desk can be overheard - phone rings - 'doctors surgery' - 'sorry what number -

what is the problem' - another phone rings - it was Gillian Oats. 9.10

Patient leaves consulting room.

Next patient arrives for Dr Dixon - directed to first floor waiting room.

Dr Dyer speaks to reception on intercom -advised that nobody is waiting. Conversation behind reception' - 'how do they expect to speak to a doctor at 8.30, Dr Dixon, Dr Heardman, Dr Francis ...!' Arrangements on phone being discussed. 8.50 Small talk by reception staff clearly audible. Two 9.15

other members of staff arrive and go into reception.

Two patients waiting.

Family group leave consulting room (mother, daughter and small son).

'5.20, Dr Francis' - telephone appointment confirmed.

General impression - hard surfaces, poor acoustic privacy.

Teenage girl arrives drinking carton of juice. 'Betty Watson - surgery 2 - on your right'. 'Wednesday - 9.30 Thursday?' 8.55 'What kind of injections - holiday injections -

Two more patients (arrive - mother and daughter) browse through heap of magazines.

Internal location of waiting room limits views to outside. 9.20

'Sharon Davies' - called by doctor.

'Christine Muse' - called by doctor. 9.22

No response to either name.

'Which vaccines?' - telephone conversation easily overhead.

Well illuminated, cool colours, hard surfaces but carpeted - yet sound reverberates around. 'Surgery 4 is free - upstairs'. 9.00 Patient leaves consulting room.

Once again telephone conversations clearly overhead.

'Valerie Watson - surgery 2 - on your right'. A quiet moment - but conversation soon starts again in reception.

Looking around there is a rack of pamphlets and 9.27 a noticeboard. No other pictures - would flowers or planting or a fish tank provide visual interest? 'Judith Chapman' - called by doctor (after receptionist takes in mug of coffee to doctor). Older woman patient arrives.

Three women now waiting in ground floor 9.30 reception area. Teenage girl returns from consulting room and leaves with her mother (I assume).

'Mrs Crawford - surgery 2' - patients not clear which surgery to enter - numbers on doors not easily seen - but on moving seat I see that name plates on surgery doors do have numbers. Mother and small daughter arrive in waiting room.

High noise level.

Next patient called.

Next patient arrives at reception desk.

Woman stands and goes over to rack of leaflets

- picks a selection and returns to seat.

One patient with child now in waiting room -

child exploring and playing with toys.

Mother and child leave from first floor.

Quiet spell.

Little happening.

Doctor leaves surgery, door ajar, disappears into reception.

Nurse comes along from treatment room with plastic bag of items to restock surgery 2.

Doctor returns to surgery 2.

Woman at reception - some discussion - then leaves.

Another discussion on the phone making an appointment - suggested times offered for appointment clearly audible. Another woman arrives to wait in ground floor waiting area.

Women and child leave with friend who now has seen a doctor.

Indian lady at reception - some language difficulties.

Woman arrives - directed upstairs - 'just knock on the door'.

No patients now in waiting room on ground floor.

Computer printer heard (from surgery 2?) 'Its gone very quiet' - overheard from reception. Phone rings - not quickly answered. Man at reception - 'you need to get those from DSS' - phone still ringing. Young woman in sari arrives in reception - 'what is your family name?' - language problems and misunderstandings - 'S-I-N-G-H?' - the computer is off - family registration queries - 'have a seat upstairs - when you make an appointment that's the name you must use'. Man arrives and leaves reception desk. 'I've a medical - Offshore Medical?' 'Mr Smith - that's right - just come round'. Patient leaves surgery 1.

Member of staff arrives and enters reception area.

Mr Smith - sitting in reception area filling in medical form.

Figure 4.13 West Road Surgery, Newcastle upon Tyne: ground floor plan. Architect: Geoffrey Purves Partnership
Figure 4.14 West Road Surgery, Newcastle upon Tyne: first floor plan. Architect: Geoffrey Purves Partnership

Conclusions

There are a number of obvious advantages now enjoyed by the refurbished building including:

• A huge improvement in the appearance of both the exterior and interior of the building. This has led to the building being shown greater respect by the patients.

• The building has now been completed and open for approximately 12 months and there are no signs of graffiti.

• Also, there has been no vandalism, except minor damage to the main staircase wall, and some petty thieving such as the stealing of the practice vacuum cleaner during a surgery session.

The building, therefore, has more 'dignity and presence' in the community. However, there are a number of remaining problems among which I would include the following points:

• The main waiting room displayed a slightly claustrophobic atmosphere.

• Dr Francis had previously conveyed to me the doctors' concerns about sound transmission in the first floor waiting area and it was very apparent in the main ground floor waiting area that the overhearing of conversations from reception staff by patients could give rise to breaches of confidentiality.

• Although the ambience of the ground floor waiting area was comfortable, well illuminated, pleasantly decorated and warm, the atmosphere did not seem to me to be especially friendly or relaxed. The very limited views to the outside, and lack of any other points of interest means that there is little visual stimulus. Would some internal planting, pictures on the walls, or a fish tank provide some visual interest? The hard wall surfaces do not help the absorption or muffling of conversations coming from the reception area. Also the hard plastic chairs do not help to improve sound absorption.

• These shortcomings result in the activities of the reception area easily catching the attention of patients waiting for their appointment. If they are not reading, or looking after a child, the reception area offers a focal point for patients to watch and listen, to which could lead to embarrassment for both patients and staff.

• The method of calling patients to the consulting rooms for their appointments seemed to vary between individual doctors and reception staff. Sometimes an intercom was used, sometimes a doctor came out to the waiting area to invite the next patient to enter for examination, and sometimes the reception staff called out a name and directed the patient to a particular consulting room. Is this variation a result of the doctor's personal preferences or is more discussion required to clarify the policy?

All of the above points, both positive and negative have aspects of management issues and design issues which merit further debate. I was left with the impression that although significant progress had been made in the overall quality of the building and the medical facilities now available to patients there is still room for refinement and improvement in the operation of the waiting rooms. I am sure this could be done for a very modest budget which would be cost effective and beneficial to patients, doctors and staff.

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