The SEGD/Hablamos Juntos Healthcare Symbols - Will They Work?

Paul Mijksenaar, Fenne Roefs

Amsterdam

In October 2010, SEGD proudly introduced a universal set of healthcare symbols, developed in collaboration with Hablamos Juntos (Spanish for “let’s talk together”). It is obvious that it was an enormously complex project and quite an achievement, for which we want to compliment all the many people involved.

Also, it is obviously too late for us to “talk together,” about it, so let's review the results.

Graphic symbols—or pictograms—have been used for centuries, but if we focus on symbols for everyday life, it all started with road signs in Italy in 1895 (Figure 1). About 50 years later, the Olympic Games followed, as did industry with symbols for household equipment, hi-fi products, cars, and European railways stations.

In 1972, Henry Dreyfuss published his famous Symbol Sourcebook that is still of great value today (Figures 2 and 3).  One of the most successful series of symbols was developed by the American Institute of Graphic Arts (AIGA) in 1974 for the U.S. Department of Transportation for use at public transportation hubs such as airports and railway stations (Figure 4).

However, in Europe it was found that some of these symbols, for example the symbols for “trains” and “information” (in the U.S. depicted as a question mark and in Europe as the letter “i”) lacked international recognition and have been changed. Nevertheless, one finds these symbols used worldwide and they are therefore an enormous help for passengers travelling around the globe. (Figure 5)

Hospitals (or healthcare facilities, as they nowadays are named) lacked a similar universal set of symbols. Many graphic designers designed unique symbol sets for their own clients, so that each visit to a different hospital was a surprise for the patients and their relatives (Figure 6). The only common healthcare pictogram used was a red cross denoting the presence of a first-aid facility, but use of this symbol has stopped because the Red Cross organization began to forbid its use in 2002, based on copyright ownership. Red Cross has restricted the use of the Red Cross as a trademark for its organization only.

So it was a good initiative of the SEGD and Hablamos Juntos to start a project to develop a universal set of healthcare symbols. Unfortunately, the result is dubious and not in accordance with the expertise and knowledge gathered by cognitive psychologists and many other professionals who contributed to the International Organization for Standardization (ISO) and national standard institutions.

One of the basic rules of symbols is that they can never be considered “self explanatory.” Symbols should be considered as a visual language and as with any other language, their meaning has to be learned. Thanks to their pictorial clarity, the meaning of some symbols can be guessed, provided they are encountered in the appropriate context (airport, hospital, rail station, Olympic Games). Curiously enough, many road signs lack a visual cue to their meaning (like the signs for “no parking,” “major road,” and “no entry”), but since learning their meaning is mandatory for car drivers, they still work (Figure 7). That is, they work to a certain extent because many symbols still are misinterpreted or confused with other symbols.

According to the ISO standard for testing public information symbols (ISO 9186-1:2014), a symbol should be understood correctly by at least 66% of the respondents in the so-called comprehension test. In this test, respondents are shown a symbol and asked to give its meaning. Two judges score the answers as “correct,” “wrong,” or “wrong and opposite to intended meaning.” In case the symbol is misinterpreted too often (> 34%), the pictogram may only be used in combination with an explanatory text.

Another rule of thumb is that symbols will only work if they refer to a concrete and familiar meaning.

When the above-mentioned rules are applied to the set of healthcare symbols developed by SEGD and Hablamos Juntos (Figure 8), it becomes clear that many of the symbols are not effective. It is very likely that some visitors or patients of a healthcare facility have no idea what kidneys or teeth look like. They will fail to recognize the symbol for “Kidney'”(CM22) and “Dental” (CM29). The same applies for “Alternative/Complementary” (CM11), “Nutrition” (CM10; can also be a hospital shop or buffet), “Laboratory” (CM12), which looks almost the same as “Pathology” (CM13), “Oncology” (CM14). Also “Mental Health” (CM16), “Neurology” (CM17), and “Dermatalogy” (CM18) are visual riddles.

Many of the symbols do depict a clearly recognizable pictorial element, but their meaning does not follow from the image (Figure 9): “Inpatient” (CM04), “Outpatient” (CM05), “Diabetes (Education)” (CM07), “Nutrition” (CM10), “Infectious Diseases” (CM28), “Interpreter Services” (FA10; with human figures cut in half!).

It is disputable whether there is a need for symbols for facilities that patients will (almost) never or never visit without staff guidance, such as “Laboratory,” “Pathology,” “Cath Lab,” “MRI/PET,” “Medical Library,” “Medical Records,” “Surgery,” and “Anesthesia.” Maybe it is assumed that staff will also benefit from using symbols.

Then there are cultural issues. For instance, the symbol for “Pharmacy” (CM06) will never work outside the U.S. (Figure 10). Remarkable and arguable is that some symbols deviate from more common (already existing) symbols like the DOT/AIGA series, for example the symbol for “Waiting area” (Figure 11).

Because of the use of similar attributes that may change in the future anyway (Figures 12a through 12f), confusion might easily occur between “Care Staff Area” (CM02), “Registration” (FA03) and “Administration” (FA05); between “Waiting Area” (FA04) and “Medical Library” (FA08); between “Ear, Nose & Throat” (CM19) and “Infectious Diseases” (CM28); between “Health Services” (CM01) and “Emergency” (FA-01); between “Laboratory” (CM12) and “Pathology” (CM13); and between “Cath Lab” (MA03) and “MRI/PET” (MA04).

Furthermore, there are serious doubts about many of the symbol sets’ “metaphorical” visualizations (Figure 13), such as the cogwheels in “Mental Health” (CM 16; cogwheels are used in the graphical user interface of the iPhone to indicate “Settings”), “Social Services” (FA11), “Nutrition” (CM10), “Chapel” (FA12; clearly a Christian building), and “Oncology” (CM14) (Figure 16). Similar symbols such as FA11 and CM14 are used, for example, for “carwash” and “Handle with Care” for packaging purposes (Figure 14).

Then there is the “Red Cross issue” (Figure 15). For decennia, a red cross on a white square or circular background has been used to indicate “health services,” “first aid,” “emergency,” and “ambulance.” Later came differentiation by ISO: a white cross on a green background for “first aid” (ISO 7010 symbols; E003 for ‘First Aid’ and E004 for ‘Emergency Phone’) and a green cross for pharmacy in most countries outside the U.S. (Figure 16). As mentioned, the Red Cross organization has decided to limit the Red Cross symbol to its own use only. The Red Cross wrote letters to all public organizations, such as airports but also department stores and movie and theater producers, to stop using the red cross to indicate hospitals, nurses, ambulances, first aid kits, etc. At Amsterdam Airport Schiphol, we reversed the colors of the first aid pictogram to a white cross on a red background (the original colors of the Swiss flag!), without any complaints or misunderstanding by the visitors and passengers (Figure 17).

In most Islamic countries as well as in Israel, the red cross was already banned as being a reminder of Christianity. Here, the green half-moon symbol is used instead. Nevertheless, the Hablamos Juntos project chose a white or black cross for “Health Services” (CM01), “Care Staff Area” (CM02), “Immunization” (CM09), “Ambulance” (FA02), “Administration” (FA05), and “Pediatrics” (CM26). We doubt if this choice can survive for long in any multi-cultural environment (Figure 18).

Finally, the Universal Health Care Symbols don’t seem to include symbols such as “exit,” “emergency exit,” “information,” “main hall/lobby,” “restaurant,” “shop/newsstand,” “restrooms” (e.g., family restroom) as well as many mandatory symbols like “no entry, “wheelchair accessible,” “no cell phones,” etc. These symbols should be an integrated part of the complete series.

We are sure that the majority of the Hablamos Juntos symbols will fail any comprehensibility test and therefore must be learned. This is a weak starting point: How can visitors learn these symbols? It is not expected that they can be learned through regular visits to a healthcare facility, because most people (luckily) will not visit them very often. Even for people who do make regular visits to a healthcare facility, it is still doubtful that they will correctly learn the meanings of the symbols (as is the case with transportation symbols which people see frequently throughout their life). Furthermore, without additional explanation, these symbols will be learned only by trial and error, causing stress, which is of course exactly what one should try to avoid in a hospital.

One of the main problems with signing of hospitals—especially in urban areas—is that a major part of their users have reading deficiencies. An important consequence of this deficiency is the lack of general knowledge of their environment. This means that symbols with strong medically related content will not help them, either. Knowledge about medical practices is required to be able to understand what some symbols refer to.

The use of pictorial symbols to indicate different healthcare services and departments should be limited to those that are universally recognized and interpreted correctly by the great majority of users. For many healthcare services and departments, this is simply not possible due to the fact that the public cannot be expected to have enough knowledge about these services and departments to be able to recognize a pictorial representation.

A better way to help visitors fundamentally—besides learning the hospital terminology itself and personal guidance by hosts—might be to provide everyday visual but arbitrary cues. Since the meaning of the symbols must be learned anyway, the symbols don't have to stand for a medical service but can be chosen based on other features. A limited number of clearly distinctive, recognizable and familiar forms may thus do a better job than medical symbols (example: standard, copyright-free computer font symbols, Figure 19). An interesting attempt in this direction is the signing of the Children's Hospital in Boston, where everyday objects are used to indicate different departments: ship, moon, flower, fish, and top hat (Figure 20). There have also been many attempts to create a global/universal set of symbols instructing patients how to use medicines (Figure 21).

So it is conceivable that hospitals can use commonly understood pictorial images—the function or meaning of which are explained at the entrance or during registration by receptionists, or multi-lingual directories that could be shown in print, on interactive screens, or even downloaded onto smart phones. This way, it is explained to visitors that, for instance, following the apple symbol will guide them to Neurology, while the symbol of a bee will take them to Ear, Nose & Throat and the symbol of a tree to Genetics, etc. People only need to hear which symbol to follow to their own destination. Maybe Disney could be a “sponsor” and lend their famous characters like Mickey Mouse, Tinkerbell, etc., so the symbols will be usable and highly appreciated all around the world.

To conclude, we have serious doubts if the current series of healthcare symbols will work as they were intended. At least some of the choices made should be reconsidered before unrolling them worldwide.

Acknowledgements
We would like to thank Dr. T. Boersema for his valuable feedback and corrections on the description of the ISO symbol testing method.

About the authors

Paul Mijksenaar is founder of Mijksenaar wayfinding experts, Amsterdam and New York. As professor at Delft University of Technology, Paul introduced the application of human factors and psychology in the specific field of information design. He is the author of numerous scientific publications and books including Visual Function, an introduction to information design and Open Here, the art of Instructional Design.

Fenne Roefs (MPsy) is a senior project manager at Mijksenaar, a wayfinding design agency. She regularly lectures at Dutch design colleges and universities, and, as a cognitive psychologist has published several articles on ergonomics and wayfinding.

Figures
1. Road sign, Italy
2. Cover of Henry Dreyfuss’ Symbol Sourcebook
3. Category “Medicine” in Symbol Sourcebook
4. First edition of Symbol Signs by DOT/AIGA
5. “Rail transportation,” DOT/AIGA (left) and ISO 7001
6. Symbols for the “Westeinde Ziekenhuis” (hospital), The Hague, Netherlands
7. European road signs
8. Examples from Hablamos Juntos series
9. Examples from Hablamos Juntos series
10. Example from Hablamos Juntos series
11. “Waiting area” symbols (l-r) Hablamos Juntos, DOT/AIGA, ISO 7001
12. Examples from Hablamos Juntos series
13. Examples from Hablamos Juntos series
14. Symbols similar to FA11 and CM14 for “carwash” (France) and “Handle with Care” for packaging purposes
15. Red Cross ambulance
16. ISO 7010 symbols E003 “First Aid” and E004 “Emergency Phone”
17. “First Aid” symbol at Amsterdam Airport Schiphol
18. Examples from Hablamos Juntos series
19. Example of standard (copyright-free) computer font symbols
20. Icons used on signage at Children’s Hospital, Boston
21. One of the many attempts to create a global visual “Esperanto,” a series of instructions on how to use medicines

Link to the original Hablamos Juntos project here.

SEGD is committed to the continuing effort of creating a strong symbol system for use by the community. Please add your comments to the dialog below.

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Comments

The SEGD/Hablamos Juntos Healthcare Symbols

First, I don’t understand the context Miijksenaar was given for his review. In other words, will these sort of reviews be a running series of peer reviews on the order of David Middleton’s journal or is this just one persons take on the usability of the healthcare symbols? If it’s the latter, I have no problem with the article, if it’s the former I strongly suggest all editorializing be removed so as not to show the bias of the reviewer. While I agree completely that the symbols don’t work (I always have and pointed this out ad nauseum during their development! It’s not our finest work.), Miijksenaar is rather loose with his “facts", I don’t agree Boston Children’s is a good example of what works nor that Disney should sponsor children’s hospitals. Hopefully a clarification is coming soon.

 

 

A way forward?

This is a comment from a member. Paul felt that he needed to start a conversation with the community on how we can continue the good work that was started to create a set of Healthcare symbols. In order to be published in the Journal, papers have to go through the SEGD Education Committee Peer Review process.

Many people in the community did great work to bring the Hablamos Juntos Healthcare Symbols project to fruition.

Jamie Cowgill needs special recognition for her work to bring in the grants that made the project possible in the first place and then lead the first phase. Thank you Jamie for all your hard work on the project.

There is a lot that can be said about the process that could have been better. What I hope will transpire from this conversation and I think what Paul was hoping to begin is that that we as a community can work in the spirit outlined in the projects executive summary which states that:

"After the release of the original USHC set, it became clear that the selection, design, and integration of symbols into one unified set—a set that could be adopted universally by health care facilities of varying size, function, and complexity—would be an ongoing process”

Steven, it has been over 10 years since the project started and it is probably time to review and update what needs improving regardless of the past. I would like to declare an amnesty on the past so that we can concentrate on how to improve the set of symbols we have. Can we focus on a discussion about what steps need to be taken to bring the work up to the right standards especially at the range of scales necessary to be considered effective learnable symbols with today's technology.

Let's focus on a positive conversation about volunteer help to "fix what needs fixing" or retire what does not work as an interim step so that the good symbols can stand proud and represent us correctly as there is no funding at this moment to do further testing. But how to fund a third phase, who runs it, how decisions are made etc could certainly be a part of the conversation and a good consolidation of lessons learned for any future research work by the community.

Palm Treo 650

Clive: thank you for the clarification on the post. It's intent is much clearer to me now. I'm in complete agreement that we "fix what needs fixing" and move forward. And also agree the SEGD community owes Jamie some gratitude for her work in this regard.

Anyone remember the Palm Treo 650 smart phone? I do, I had one in 2004 when the original symbols were developed. Who knew at the time the extent to which smart phones were going to impact our lives. I believe the screen resolution was something like 320x320 pixels. Not exactly earth shattering by today's standard but cutting edge at the time. I posited then that the symbols were too complex to be read on handheld devices (at ±1/8"sq) or on a dot matrix or thermal printer for that matter. I don't believe this was ever factored into the original symbol design. 

Let's follow the spirit of the "projects executive summary" as you suggest, weed out the symbols that don't work (perhaps reducing them to ±1/8"sq and viewing them on different devices with differing screen resolutions and printing them with a thermal printer will quickly identify the weak symbols) focus on the symbols that work. It will be interesting to see how many, if any make the cut. 

Perhaps a small group of interested designers can gather at the Chicago conference, test the symbols as mentioned above, develop a short list of successful symbols, decide if they are graphically compatible, if so, great, if not, have one renowned symbol design volunteer tweak the symbols (v2.1) and move on to v3.0 when funding and processes are in place.

Clarification

Steven’s second assumption is right. Fenne and me are ‘just two persons’ (Paul is also a SEGD member) who care about the usability of healthcare symbols’. We were not involved in the project and had to wait for the final results before we could comment on them. 

We are not aware about being rather ‘loose with the facts’ regarding the Boston Children symbols which we just alluded to show an example of an interesting approach about communicating by everyday objects. As are the characters like Mickey Mouse, Goofy and Donald Duck which every child wil recognize but never could be used without the courtesy of their creators, Disney.

We are happy to see that our essay might contribute to gain a better result in ’talking together’.

 

Paul Mijksenaar & Fenne Roefs

 

 

 

Great article to read. But I am not sure that these graphics will work or not. But one can read some interesting things about healthcare industry. Check over here