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This webpage is designed to make available historical data related to the development and implementation of Universal Health Care Symbols (UHCS).

PHase I - HOW UHCS WERE DEVELOPED

This section includes historical materials and describes past activities undertaken to develop the original 28 UHCS.

Project Oversight
Symbols Testing
Symbols Survey Progress
Request for Application-Pilot Site Facilities
Call for Participation
Pilot Site Testing


On this page, we have archived information related to Signs That Work that is now outdated, but which may still be of interest to some visitors to the site. In particular, this page contains information about the process used to develop the set of 28 universal health care symbols now available.

Signage project oversight

The Signs That Work project of Hablamos Juntos is a collaborative effort on the part of many individuals and groups. A steering committee, which included JRC Design, SEGD, Hablamos Juntos NPO and RWJF, met regularly to guide the development and testing process. The persons involved and the teams which supported this work are described.

Symbols Design Team

The Symbol Design Team consisting of six graphic designers, with experience in symbol design and/or health care way-finding and signage system design, and an expert in symbols evaluation were commission to design the top 20-30 most commonly needed health care symbols and to provide suggestions for how existing Department of Transportation images could be incorporated into the new symbols system. The team will develop guidelines and standards for health facilities to use the new system along with promotional materials, designed to increase public understanding of the symbols.

Designers

Jack Biesek, President Biesek Design
Gladys Brenner, President of AB Design, Inc.
Margaret Faye, President FayeWorks Design
Healther Merrifield, Director of Pictoform
Kate Keating, President Kate Keating Associates
Wendy T. Olmstead, Assistant Director of Marketing Communication, Ivy Tech State College, Lafayette, Indiana
Todd Pierce, President of Pictoform

Team Staff

Jamie Cowgil, JRC Design
Jim Bolek, JRC Designs

Project Advisory Committee top

A group of respected health leaders with a strong interest and demonstrated experience in the language barriers field advise the steering committee, help identify potential applications in health care, develop strategies to disseminate the symbols system nationally and explore ways to they can become the baseline standard for health signage.

Advisors

Joan Barlow, Robert Wood Johnson Foundation
Cástulo de la Rocha, AltaMed
Pamela S. Dickson, Robert Wood Johnson Foundation
Deeana Jang, Office of Civil Rights, U.S. Department of Health and Human Services
Edward L. Martinez, National Association of Public Hospitals and Health Systems
Hugo Morales, Radio Bilingüe, Inc.
Guadalupe Pacheco, U.S. Department of Health and Human Services
Yolanda Partida, Hablamos Juntos

Paul M. Schyve, Joint Commission on Accreditation of Healthcare Organizations
Victoria D. Weisfeld, Robert Wood Johnson Foundation

Technical Advisory Committee

During the symbol development and wayfinding testing process a committee of design experts in the healthcare, symbol, regulatory and testing fields provided guidance. This Technical Advisory Committee (TAC) of seven professionals advised the symbols project advisory committee on the validity of the overall testing process, assisted in the creation of a testing process for the use of symbols in the healthcare environment, and advised on the best practices for symbols or pictograms in the wayfinding, print and web environment.

Technical Advisors

John Bosio, Hillier
Dan Clements, Karlsberger Companies
Ken Ethridge, AIA, RIBA, ASI-Modulex, AIA Health Care consortium
David Gibson, Two Twelve Associates, AIGA Board
Phil Garvey, Penn State
Lance Wyman, Lance Wyman Ltd
Roger Whitehouse, Columbia University School of Architecture

Committee Staff

Craig Berger – Director of Education and Professional Development for the Society for Environmental Graphic Design

Association Partners

In addition a group of association principals, government officials and testing experts observed and commented on the design and testing process as well as the best practices guidelines. After the symbols have been developed, this group will assist in developing an educational program for their use.

American Institute for Graphic Arts (AIGA), Richard Grefé, Executive Director
The Center for Health Design, Sara Marberry
AIA Healthcare Committee,
Healthcare Architecture (AAH)
The Academy of Architecture for Health

Steering Committee

The steering committee coordinates and integrates the various components of the signage project. This committee is composed of members of the following groups: the National Program Office, JRC Design, the Robert Wood Johnson Foundation, and the Society of Environmental Graphic Design.

symbols testing top

Public information symbols used on signs to help patients and visitors navigate in health care facilities have rarely been evaluated from the user perspective in support of designing a symbol set prior to signage installation. An important component of this project is the comprehensibility estimation surveys that will be administered to multilingual users during the symbol design phase. Four rounds of surveys will be used to determine which symbols for 20-30 referents are most meaningful across languages.

Users of health care facilities in ten Hablamos Juntos demonstration sites were invited to participate in the survey. The locations of the Hablamos Juntos demonstration sites provided for the gathering of a national sample of health care facility users in ten different states. Hablamos Juntos site leaders recruited community volunteers from limited English-speaking populations; providing a sample of approximately 100 accessible and cooperative adult patients or visitors who speak a variety of languages for each round of testing. Participants representing four languages groups, English, Spanish, Indo-European and Asian languages from the Hablamos Juntos demonstration sites were included. Those participants formed a non-probability convenience sample; different for each round. Each Hablamos Juntos demonstration sites designated a survey administrator. Three rounds of surveys were administered in person by survey administrators trained at each site working interpreters. In many cases, interpreters who speak the participants' language will ask the questions in the respondents' language and the administrator will fill in the survey as they answer. The survey results were entered on-line by survey administrators and quality checked by the National Program Office against the original surveys. Round 4 was an on-line matching survey targeting English speakers.

Symbol Survey -Comprehensibility Estimation Testing

The Comprehensibility Estimation test is an International Organization for Standardization (ISO) method for public information symbol testing. Each survey instrument consisted of 20-30 open-ended questions with 100-180 unique symbols (five to six symbols per referent). The research question asked for each referent was “Which public information symbols for this referent is the most meaningful to users of health care facilities”, meaning that they serve to cross language boundaries, for the user populations in the regions surveyed?

For each referent in the study, respondents are presented with 5-6 symbols. They were then asked to assign a number to each symbol representing the percent of the U.S. population that speaks their language who they think would understand a given symbol to mean a given referent. To see a sample page from the survey, click here. To participate in Round 4 of the symbols survey, click here.

A team of graphic designers, experienced in symbol design, created the public information symbols tested in each survey round. Results from each rounds, the comprehensibility estimates, were used by the Design Team to guide the redesign/refinement of new symbols and to determine the final set of the health care facility public information symbols developed through this project.

Symbol Survey Schedule

2004
September
Round 1
2005
January
Round 2
March
Round 3
June
Round 4 - General Public

Referents

What is a referent? Referent is a word for a real world object, place or concept that a symbol is meant to represent.

Key signage terms currently used by health facilities were prioritized in order of importance from an inventory taken at Hablamos Juntos demonstration sites. The highest priority terms have become the referents for which symbols are being developed. The following referents were selected for the project through a terminology survey conducted in the Hablamos Juntos demonstration sites.

To see a sample of the survey click here.

Ambulance Entrance

mammography
Billing Department medical records
Cardiology oB clinic
Care Staff Area oB/GYN
chapel oncology
diabetes outpatient
emergency pediatrics
family practice clinic pharmacy
immunizations physical therapy
infectious diseases radiology
intensive care registration
internal medicine social services
interpreter services surgery
laboratory waiting areas

Symbol Survey Progress top

Status Report

As of July 2005

We are now in the fourth and final phase of Signs That Work. Round 4 participants will be asked to match the 20 existing symbols with referents and their definitions. Click here to participate in this exciting final stage of our project.

Completed Survey Rounds

The first three rounds of symbol testing took place from the summer of 2004 until March 2005 and pared 154 symbols and 28 referents down to 19 and 11, respectively. Participants estimated what percentage of the population that speaks their language would understand an image to mean the intended referent. A variety of symbols (5-6 per referent) were presented with the referent and its definition on the same page.  The emphasis was on reaching participants of English, Spanish, Indo-European and Asian language groups.  The highest rated symbols for 17 referents were compiled into a matching test for Survey Round 4 and used in pilot site testing.

Symbols for 11 referents fell short of the threshold for comprehensibility.  These included two distinct groups; those that came near the threshold (70-80%) and those that received ratings of 50% or lower.  Terms such as cancer/oncology, diabetes, infectious disease, interpreter services and internal medicine received the lowest scores.  The fact that this may not be a design issue underscores the importance of public education once this project is completed.

Pilot Site Evaluation

Pilot site testing took place from April through May to determine how the tested symbols can be used effectively in health facilities. A symbol/referent matching test was administered; collateral materials such as maps and printed materials were also tested. The on-site evaluation design, though intense both in terms of schedule (4 sites in 5 weeks) and in content, was successfully executed by Craig Berger of SEGD and Phil Garvey ( Penn State). Pilot site volunteer staff offered insights about their current signage system and made recommendations about the use of symbols in way finding.

The participants – visitors and patients in the pilot site facilities – had language proficiency ranging from little or no English (an interpreter gave instructions to these participants) to sufficient English to take the test on their own. The participants were of four language groups: English, Spanish, Indo-European and Asian. Tested languages from the latter two groups varied according to the demographics of the site area and included Creole, Nuer, Hindi, Amharic, Portuguese, Loatian, Mandarin, Cantonese and Vietnamese. Patients of these language groups, besides completing the matching test, were also timed in finding six destinations on the site, four with symbols signage and two without.

See our Media Center for local television and print media coverage on the pilot sites. The Grand Island Independent covered the Saint Frances Medical Center visit and the Atlanta Journal-Constitution published an article on the Grady Health System visit (5/05/05). Technical reports describing the design and survey testing of these symbols as well as the pilot site testing will be available on our website in September 2005.

Timeline

Team meetings and project milestones are listed in the Signs That Work calendar.

Request for Application (RFA) top
Seeking volunteer health facilities to test symbol-based signage

Four health facilities that meet project criteria are needed to support this evaluation. This RFA seeks inpatient or outpatient health facilities to volunteer to serve as pilot sites for this project. Pilot sites will help establish the usefulness of symbols as a way finding tool in health care facilities and contribute to the development of guidelines for the successful application of symbols.

Participation as a pilot site is voluntary and at the expense of the facility; no compensation or reimbursement of expenses is provided. Successful candidates will have to meet project criteria and demonstrate commitment for the evaluation of a symbol based signage system for health facilities and provide the resources necessary to participate as a pilot site. In return, volunteer facilities will be recognized for participating in a national evaluation of symbols. In addition, through the pre and post audit design, pilot sites will gain a comprehensive signage audit and customized way finding solutions developed by leading national experts in symbols and way finding signage.

Click here for a copy of the Request for Application.

Timeline

 

February 5, 2005
Pilot Sites Announced
March 15, 2005
1-day Orientation Mtg w/Pilot Sites
March 17, 2005
TAC Meeting 5 live (last)
April 4 - 6, 2005
Site Visit
April 18 - 20, 2005 Site Visit
May 2 - 4, 2005 Site Visit
May 16 - 18, 2005 Site Visit
May 27, 2005 Pilot Site Testing Completed

 

Frequently Asked Questions

Inquiries concerning any aspect of this RFA should be submitted in writing, either by fax or electronic mail. Telephone inquiries will not be accepted. All written questions received by October 25, 2004 will receive a reply via email or will be posted in this section. We will attempt to answer questions submitted after this deadline. Check back for new questions.

Fax: To submit questions by fax indicate on fax cover sheet subject line RE: QUESTION FROM RFA RESPONDENT and fax to 213.743.1553.

Email: Submit questions via electronic mail with subject line RE: QUESTIONS FROM RFA RESPONDENT and email to: info@hablamosjuntos.org.

Following are a list of common questions:

  1. What is the timeline for the RFA?
  2. How do I apply?
  3. What if I have questions about the RFA?
  4. Is there a way for me to ask a question directly about the RFA?
  5. How will pilot sites be selected?
  6. How many pilot sites will be selected?
  7. What criteria are pilot sites expected to meet?
  8. Will every site receive the same set of symbols?
  9. Will I be able to choose where the signage is placed?
  10. Will pilot sites receive compensation for participating?
  11. What are the benefits of being a pilot site?
  12. Are symbols being developed for all the terminology found in health signage?
  13. Will every site use the same set of symbols?
  14. Will I be able to choose where the signage is placed?
  15. How will the new signage be installed?
  16. Will the facility receive a copy of the final report or conclusions of the evaluation?
  17. Who will pay for sign fabrication for the project?
  18. What costs will be incurred by participating facilities?
  19. I am a designer working with the health care facility. Can I get involved with the process?
  20. My facility is small or in an urban area. Ten locations on one floor may be a challenge for smaller facilities. Will this requirement be used to disqualify applicants?
  21. Will the new signage be made compatible with existing signage?
  22. Will exterior signs on a campus be part of the testing?
  23. What happens to the existing signage during the testing?
  24. What will be done for signage needs beyond those addressed with symbols?
  25. Will other signage, not specific to the locations required for testing, be part of the audit?
  26. What formats are acceptable for the blueprints/layouts of our hospital?
  27. In regards to "Facilities Management" focus groups, can members of the Housekeeping staff be included?
  28. Can you clarify the format of the application? We are confused with the last sentence where it states the application should be on white paper and black ink. The application should be all electronically submitted right?

Call for Participation top

SEGD is undertaking an enormous new research project that will redefine the way we look at symbols in wayfinding and you can be involved!

Hablamos Juntos: Improving Patient-Provider Communication for Latinos is a national program of the Robert Wood Johnson Foundation to develop solutions to language barriers to health care. One objective of Hablamos Juntos is to develop and test a set of symbols or pictograms and terminology that designers and health care administrators can use to create friendly facilities for those with limited English ability. The project will produce a set of tested symbols for common health signage terminology with guidelines and standards for using the new system in health facilities. Promotional and educational materials to increase public understanding of the symbols will also be developed. Collectively these products are referred to as a “kit of parts.” The new health symbology system (the “kit of parts”) will be made available at no cost to the interested public through SEGD, Hablamos Juntos and the Robert Wood Johnson Foundation. For more information about the project visit www.hablamosjuntos.org.

Four health facilities will participate in pilot testing of a newly designed symbols-based signage system. Temporary signs with the symbols set to be tested are needed. The testing will be done mostly in April and May of 2005. The purpose of this request for applications is to find four fabricators to construct temporary signs for four pilot healthcare facility sites to participate in this project. Each fabricator will be asked to build and deliver signs to one pilot test site.

The benefits of participation are enormous, including respect among your peers, sponsorship in SEGD publications, assistance to SEGD, and the chance to be part of an enormously influential study that can reshape the way we look at healthcare facilities. Your name will appear as a participant on all major publications coming from this project including the Healthcare Symbols White Paper that will be included as part of this project. Any specific questions regarding the project and benefits as a participant should be sent via e-mail to craig@segd.org.

Sign Descriptions

The signs for the pilot projects are expected to be made out of foam core, black and white and installed with putty or another temporary adhesive backing. Some signs used on building exteriors or free-standing exterior signs may be banner signs. The signs will be both overhead identity elements and wall mounted elements. The sign elements will be provided by JRC Design in Illustrator using scaled and camera ready art.

Sign Size

Identification signs will be no more than 18” wide and 30” high
Wayfinding and overhead signs will be no more than 60” wide and 24” high

Sign Numbers

We expect to need about 30-40 temporary signs for each facility. This application is for only one pilot location.

Sign Materials

Alcan, the maker of foam core has agreed to contribute the materials for use in the making of foam core signs. This does not include banner signs.

Delivery

The signs can be boxed and delivered to the pilot sites directly.

Application Requirements

Contact Name
Firm Name
Address
Phone Number
E-mail Address

Short (One paragraph) summary of firm experience in one of the following areas:

  • Healthcare facilities
  • Corporate facilities
  • Universities or other institutional facilities

Understanding of the Requirements of the Project

Please include a paragraph explaining your understanding of the requirements of fabrication based on the description of the project above.

Additional Comment and Information on How to Achieve Project Objectives

Please include a paragraph explaining any additional comments on how project objectives may best be achieved. These comments can include but are not limited to:

  • Best approach for delivering signs to the site
  • Better temporary adhesive approaches for the signs to be installed
  • Better exterior sign approaches than banner signs

Application Documentation

Submission should be by Microsoft Word document with the letterhead of your organization at the top. This application should be sent via e-mail to segd@segd.org.

Deadline for Submission

January 17, 2005

Pilot Site Testing top

In February of 2005, Hablamos Juntos announced the selection of four pilot sites to help answer whether symbols or pictograms can help limited English speaking patients navigate health care facilities.

The symbols successful comprehensibility surveys conducted in the ten Hablamos Juntos demonstration sites were used in pilot site testing. Pilot site testing will also inform the development of guidelines for successful symbols use in health care signage for literacy challenged populations.

The goal of pilot testing was to determine how well the new symbols are recognized in a way finding system. This includes whether (a) symbols are associated with the intended destination and (b) whether symbols are easier to detect when they are used with:

  • text and arrows
  • cards explaining the symbols
  • map support

In addition the pilot site evaluation will help to inform guidelines for symbols use:

  • on way finding signs
  • in conjunction with numbers, text and color on signs
  • in conjunction with maps, instruction cards and graphics
Pilot Site Testing Schedule
5-6 Apr Site visit -Grady Health System – Atlanta, GA
17-18 Apr Site visit -Kaiser Permanente - San Francisco, CA
27-28 Apr Site visit-Somerville Hospital – Cambridge, MA
May 16-18, 2005 Site visit -St. Francis Medical Center - Grand Island, NE

Pilot Site Evaluation Design top

In each facility the pilot site testing process began with a one-day orientation meeting. The evaluation design included an audit before and after the symbol-based signage system was installed to analyze the effectiveness of the facility’s signage system. In addition, exterior way finding and multi-level way finding was also tested to some extent, though not as the main focus of this testing effort. A pre-test of the evaluation design was conducted which resulted in slight modifications to the proposed design described below.

SEGD managed both the pre-design and post-design audits. Pennsylvania State University Visual Communication Resource Lab prepared testing procedures, following the guidelines developed by SEGD, the Technical Advisory Committee and document outcomes. Facility staff participated in the evaluation and helped to plan and install a temporary symbol-based signage system. JRC Design worked with facilities to determine the best application of symbols signage. Temporary signage was provided at no cost to the facilities, courtesy of sign makers who volunteered to be part of the project.

The post-design audit was closely integrated with the pre-design audit to ensure that all the information was utilized in the process. The attachments submitted with the RFA application and the information obtain during the orientation meeting in Chicago helped provide pilot site facilities the basic information needed for the pre-design test and helped to customize the overall testing process for each facility. The pilot site results will inform future recommendations for how symbols can be included in web sites and other paper information.

Pre-Design Audit

To begin, an inventory of existing signage and destinations in the facilities was prepared and a plan for application of the new symbols signage was developed in conjunction with designers and facilities managers. The Pre-Design analysis consisted of four parts:

a. Focus Group of facilities staff (10-15 participants) and statistical survey to determine:

  • Best way of finding locations in each health care facility
  • Best way of finding difficulties at each heath care facility
  • Cultural backgrounds and language needs of facility visitors
  • Best way of finding needs at each facility

b. Pre Design Opinion Survey of pre-selected users (25-30 participants) to share insights and experience using the existing sign system.
c. Random Way finding Survey including 25-30 visitors and patients recruited on site to participate in testing of signage for key destinations on the premises. The survey will target limited English speakers to provide a data benchmark.
d. Health Care Site Audit based on the UK NHS Estates Site Audit Procedure and the SEGD institutional facilities audit procedure. This audit covered three areas:

  • Conceptual approach to on-site way finding
  • An inventory of signs and way finding routes in a select location of the hospital
  • Relative effectiveness of existing wayfinding in the healthcare facility

Installation of Temporary Symbols System

Based on the results of the pre-design audit, the Technical Advisory Committee developed a post occupancy survey for each pilot site. JRC Design worked with facilities staff to install the new signage in accordance with the post occupancy survey protocol developed for each site. Signs used for the study were made of foam core and placed on existing signs masked with brown paper. The temporary signs were placed with putty and tape that did not harm the facility. The signs were a modular kit of parts that offered flexibility in the testing process. Requirements for the Pre and Post Design Audits are described below.

Post-Design Audit

Once the temporary symbols system were installed, SEGD conducted a post occupancy survey customized for each pilot site, incorporating design and implementation guidelines suggested by the Design Team. The Post-Design analysis consisted of three parts:

a. 360 degree Focus Group of designers, facilities manager, key facility staff and testing staff to discuss how symbols may be integrated into the facilities current signage, sign management and maintenance programs, and the potential success of the new wayfinding system
b. Post Design Opinion Survey of pre-selected users (25-30 participants) to provide opinions of the new implemented sign system
c. Random Wayfinding Survey using 20-25 randomly selected people who will find the locations outlined by the facilities managers and Technical Advisory Committee from the pre-design audit. Again the survey will target limited English speakers recruited on site.


PHASE II – IMPLEMENTING SYMBOLS IN HEALTH CARE FACILITIES

This section includes historial materials and describes past activities undertaken to implement UHCS in four innovator health facilities.

Hablamos Juntos Signs That Work (STW) initiative identified four health facilities ready to implement symbols based signage through a RFA which closed July 1, 2008.

A team of leading national experts in symbols and wayfinding signage will support selected facilities with technical assistance and evaluation support for development of award-winning wayfinding programs using graphic symbols. Implementation is also supported by the development and testing of additional symbols needed to complete wayfinding systems in selected facilities. Facilities selected will be rewarded with recognition as innovator sites with best practice application of symbols as a practical solution in health care signage for multilingual and literacy challenged populations.

Request For Application (RFA)


For a copy of the RFA seeking Innovator Health Facilities to implement symbol-based signage click here.

RFA Timeline

RFA Released:

May 1, 2008

Deadline for Written Inquiries:

May 30, 2008

Informational  Conference Call:

June 3, 2008

On Line Application Deadline:

July 1, 2008



Conference Call

An Informational Conference Call was held June 3, 2008 to review the RFA and answer questions from prospective applicants. To listen to an audio tape of the Informational Conference Call click here.

Frequently Asked Questions

Inquiries concerning any aspect of this RFA should be submitted in writing, either by fax or electronic mail. Telephone inquires will not be accepted. All written questions received by June 27, 2008 will receive a reply via email and/or will be posted in this section.  We will attempt to answer questions submitted after this deadline.  Click here  to see Questions and Answers posted.

Email: Submit new questions via electronic mail with subject line
RE: QUESTION FROM RFA RESPONDENT
.” to: HJ Info