New Universal Health Care Symbols Can Transform Medical Facility Wayfinding
by Mies Hora, Founder & CEO, Ultimate Symbol
Author, Official Signs & Icons 2
Meeting an Important Challenge
One of the most important issues facing health care executives today is the demand for health services from an increasing number of patients with Limited English Proficiency (LEP). Federal law and accreditation standards require health facilities to post signage in the language of their patients. Meeting this basic requirement is a growing challenge as the languages spoken in a community increase and grow more diverse. In the United States alone, the number of people who speak a language at home other than English has grown significantly. This segment of the population grew by 38 percent in the 1980s and by 47 percent in the 1990s. By the 2000 Census, 47 million persons over the age of 5 spoke a language other than English in the home.
The design community needed to develop design tools and methodologies to enable access to health services for those with LEP and limited literacy. Research has shown that universal symbols are an effective design tool to assist visitors while navigating health facilities.
Advantages of Universal Health Care Symbols
Universal symbols have a variety of advantages that make them very attractive in health care settings such as hospitals and health care facilities:
> Universal symbols are much easier to implement and maintain than multi-lingual signs. They can be designed without troublesome translation processes and can be updated and changed with fewer mistakes. Translation approaches that utilize software often lead to errors when unusual accent markings or non-Latin letter based languages are used.
> Universal symbols are more easily noticed and comprehended compared to multi-lingual signs.
> Universal symbols are simpler to integrate with ADA (Americans with Disabilities Act) Guidelines because signs can be user-friendly to the visually impaired due to consistency in size and clarity of configuration.
> Universal symbols can be equally successful in simple identification signs and complex wayfinding systems. Universal symbols can also be used in combination with numbers and letters to make those systems more effective.
Genesis of the Symbol Program
The Universal Symbols in Health Care program originated with Lance Wyman’s design for the Mexico City subway symbols. In the 1970s and again in 2000, Yolanda Partida, Director of the National Program Office for Hablamos Juntos (We Speak Together), based at UCSF Fresno Center for Medical Education & Research, visited Mexico City and saw how Lance’s cultural icons had prevailed over nearly thirty years, growing with the subway system. Inspired, Yolanda wondered whether well-designed universal symbols could be used in health care environments to reach people with limited English proficiency.
Hablamos Juntos released an RFQ and commissioned JRC Design to prepare a White Paper on the feasibility of using symbols for health care wayfinding, including recommendations for next steps. The conclusion of the White Paper was not only that symbols were a viable option for wayfinding in health care, but that a set of tested symbols, publicly available, would give designers and health care facilities a much-needed alternative.
The development of the fifty Universal Health Care (UHC) Symbols (plus four alternatives) in this volume required an extensive design and research process that transpired in three phases over a period of more than eight years. With a repetitive symbol design and testing process consisting of multiple rounds of testing and hundreds of test subjects, these health care symbols represent one of the most comprehensive symbol design efforts ever undertaken. Started in 2003, the process is ongoing and will continue to evolve as more data is acquired during implementation and use.
Phase One: Core Set
Funded by the Robert Wood Johnson Foundation and overseen by Hablamos Juntos, the first 28 health care symbols were developed during the intial phase by a design team of leading health faciltity designers led by JRC Design and tested by Wendy T. Olmstead, a top symbols researcher, using testing methods adopted by the ISO (International Organization for Standardization).
The 28 symbols that came out of this work were selected from an inventory of over 220 health care terms or referents found in existing signage in health facilities located in ten different Hablamos Juntos demonstration sites around the U.S. Existing symbols, along with newly designed symbols (approx. 600 total),were collected and evaluated by the design team. For each referent, five to six symbols were chosen to be used in the first round of testing. The symbols were tested across four language groups: English, Spanish, Indo-European, and Asian, in ten states. Based upon the each round’s results, symbols were either rejected or accepted and refined further for testing.
Once completed, the symbols were field tested in a variety of health care environments in a program led by SEGD with the assistance of the Pennsylvania State Transportation Institute, as well as a technical advisory team that included Lance Wyman, Roger Whitehouse, and David Gibson. The symbols were evaluated by placing them on signs and in print formats in diverse health care settings. Wayfinding exercises were conducted with four language groups to compare navigation with symbols versus navigation with multi-lingual word signs. This testing enabled the design team to assess the symbols’ appropriateness among different cultural groups and the effectiveness of universal symbols in the health care environment. Furthermore, focus groups with facility staff enhanced the understanding of how symbols could best be implemented in various hospital settings.
The final design and management recommendations based on the lessons learned from the observations made during the wayfinding testing process in the pilot hospitals were matched to examples of best practices found in different facilties around the world. The resulting report and Best Practices Workbook, Universal Symbols in Health Care Workbook, was published in 2005 and is available at www.hablamosjuntos.org and www.segd.org.
Phase Two: Expansion
Release of the first 28 Universal Health Care Symbols marked an important milestone; the first step in a long journey toward easy-to-understand signage for all patients. With Pioneer Team funding by the Robert Wood Johnson Foundation overseen by Hablamos Juntos, the ‘Signs that Work’ project was launched to further test symbols as a tool for wayfinding systems. Initiated in 2008, the second phase aimed to accomplish three main objectives:
1. Increase the collection of UHC Symbols by producing 20-30 additional symbols while developing capacity for ongoing symbol testing and development in established Graphic Design schools.
2. Recruit and provide technical support up to four pilot sites ready to implement symbols based wayfinding systems.
3. Develop a virtual learning lab to document the implementation experience and promote awareness of symbols based wayfinding as a solution for multi-lingual environments.
Students in the University of Cincinnati’s School of Design, California Polytechnic State University, Iowa State University, and Kent State University began working on signage proposals in January 2009, led by design professors at each school. Asked to create 15-20 symbols that could be added to the first set of 28 symbols already in use nationally, each school was to develop symbols that would communicate and guide users to specific service areas and other message content not addressed in the original set of 28 symbols, such as ‘hospital admission’, ‘dental care’, ‘genetics counseling’, ‘mental health services’, ‘opthalmology’, ‘nutrition counseling’, ‘pathology’, ‘radiology’, etc.
After being reviewed in a series of recognition and comprehension tests, the symbols judged to be the best performers were integrated into surveys administered in pockets of language groups (both English and non-English speakers) in Cincinnati, Ohio; Kent, Ohio; and Ames, Iowa. Finally, the symbols that ‘made the grade’ in terms of this community user survey/testing were eventually to be made available to actual health care settings, pilot sites already working
to implement health symbols as signage. These are the Grady Memorial Hospital, Atlanta, GA (the largest hospital in Georgia); International Community Health Services, Seattle, WA; The Children’s Mercy Hospital, Kansas City, MO; and the Women and Infants Hospital of Rhode Island, Providence, RI.
Phase Three: Comprehensive System
In late 2009, as the schools’ research and design efforts were nearing fruition, Mies Hora, director of Ultimate Symbol, was engaged as a symbol design consultant for the Universal Symbols in Health Care - Hablamos Juntos / SEGD project. Known for his work in developing non-verbal communications systems, he was given the responsibility for the final design of the symbols. Working closely with project director Yolanda Partida, Craig Berger of the SEGD, and the academic research team leaders, Mies simplified many of the symbols, presenting refinements, edits, and alternate symbol elements and concepts for the project members to review, before consolidating the consensus decisions into the final symbol designs and vector artwork.
In addition, Mies revisited the original set of 28 health care symbols developed during the first Hablamos Juntos/SEGD collaboration completed in 2005. Using the new set of 22 symbols as a guide, Mies, working with his associate Christopher O’Hara, retooled the older set to enhance overall design and visual consistency, including symbol-to-field size relationships, line weights, element styling, etc. In this way, both sets of symbols were finally integrated into one comprehensive 50 symbol system (with four Imaging alternatives)
that now adheres to internationally recognized symbol design standards.
The target audience for this expanded and refined set of UHC Symbols is the community of potential and future users: health care leaders and design professionals, including architects, interior designers, sign designers as well as sign manufacturers. The general public,
to a lesser degree, is also a target audience to increase recognition value of the symbols.
An on-going capacity for symbol development and testing has now been created in graphic design schools to expand the collection and fulfill the need of future implementation projects. With the involvement, among other participants, of the Joint Commission International Center for Patient Safety and the Institute for Diversity in Health Management drawing attention to the project, this lengthy, meticulous, truly collaborative effort has the potential over time to achieve global reach.
For the upcoming Special Edition of the UHC Symbols, a selection of 42 Public Services, Information, Regulations and Warning symbols pertinent to health care settings are included in an addendum.
Program Participants / Credits
Program Director: Yolanda Partida, Hablamos Juntos National Program Office, Assistant Adjunct Professor, UCSF Fresno Center for Medical Education and Research
Symbol Testing Consultant: Wendy T. Olmstead, Ivy Tech Community College
Technical Advisory Committee: Craig Berger, SEGD; John Bosio, Hillier; Dan Clements, Karlsberger Companies, Ken Etheridge, AIA, RIBA, iZone; David Gibson, Two Twelve Associates; Lance Wyman, Lance Wyman, Ltd.; Roger Whitehouse, RIBA, FSEGD, Whitehouse & Company
Wayfinding Test Design: Phil Garvey, Pennsylvania State Visual Communications Research Institute; Craig Berger, SEGD
Managing Design Firm: JRC Design, Jamie Cowgill and Jim Bolek
Design Team: Jack Biesek, Biesek Design; Gladys Brenner, AB Design; Margaret Faye, FayeWorks Design; Jamie Cowgill and Jim Bolek, JRC Design; Kate Keating, Kate Keating Associates.
Symbol Development Team Leaders: Oscar Fernández, Associate Professor, Digital Design Program, Cincinnati University School of Design; Kathryn McCormick, Associate Professor, Graphic Design, California Polytechnic State University; Lisa Fontaine, Associate Professor, College of Design, Iowa State University; David Middleton, Associate Professor, Visual Communication Design, Kent State University
Symbol Design Consultant: Mies Hora, Ultimate Symbol; Christopher O’Hara, Design Associate
About the Author Mies Hora has been a sign and symbol maven for many years and his company, Ultimate Symbol, has published a number of the most frequently used free-source books and CDs. His most recent book/CD is Design Elements 5, an encyclopedia of visual forms. His forthcoming book/CD is Nature Icons 2.