1,175,800 ft² Tyler campus
470,000 ft² Longview campus
280,000 ft² Marshall campus


Contextual research assessment of wayfinding and patient experience at CHRISTUS Mother Frances Hospital in Tyler, Texas, culminating in strategic recommendations for signage standards and process improvements across multiple campuses in CHRISTUS Health's Northeast Texas region.


Site assessment, patient shadows, staff interviews, stakeholder interviews, analysis of HCAHPS data, audit of existing signage, process improvement recommendations, recommendations for setup of in-house signage fabrication shop, updated signage standards, updated room numbering and nomenclature system, documentation



  • Large catchment area including rural communities throughout Northeast Texas—many patients drive upwards of an hour to their appointments and are unfamiliar with the Tyler metro area
  • Exterior signage anticipated arrival on campus from the West, when in reality a significant number of patients approach the campus from the East
  • Multi-generational campus with many aging buildings felt bland and overwhelming to patients
  • Outdated branding and signage persisted throughout
  • Lack of a strategic wayfinding master plan resulted in inconsistent nomenclature

Case Study


Site assets CTMF historical 1 Site assets CTMF historical 2 Site assets CTMF historical 3 Site assets CTMF historical 4 Site assets CTMF historical 6 Site assets CTMF historical 5 Site assets CTMF historical 7
fig. a
Sisters of the Holy Family of Nazareth have been serving the community for over 140 years.

Mother Frances Hospital was founded by the Chicago-based order of the Sisters of the Holy Family of Nazareth in the early 1930s, with the hospital's first building opening in Tyler, Texas in 1937. fig. a The hospital continued to expand over the next few decades, with a 110-bed tower being dedicated in 1965. Mother Frances Hospital merged with regional primary-care provider Trinity Clinic to create the Trinity Mother Frances Health System in 1995, before further merging with CHRISTUS Health in 2016.

Throughout these eras of growth, the original 1937 Mother Frances Hospital building still stands as the anchor of an ever-evolving and increasingly dense hospital campus serving Tyler and the surrounding East Texas region. fig. b

fig. b Campus overview (present day).
CTMF History
0.9mb 17-1480_History_July17.pdf


fig. c

“I just noticed the new signs. They’re visible and colorful, but for some of the elderly it might be hard to read. I can’t see them from back here. If words were a little bit bolder—like the street signs—it would be better.” -PAT.04

We began our engagement with CHRISTUS in the fall of 2017 with a month-long contextual research assessment of wayfinding, patient experience, and staff experience at the system's flagship CHRISTUS Mother Frances Hospital campus in Tyler, Texas.

As part of this assessment we shadowed four patients from their homes to their appointments fig. c; interviewed 21 stakeholders fig. d; and shadowed nine caregivers and support staff during their shifts fig. e.

Our resulting report combined qualitative sense data from these on-site activities with audits of existing signage/architectural conditions and analysis of the hospital's HCAHPS data in order to identify problem areas and recommend design and process improvements that would cut costs, solve for processual inefficiencies, and improve patient experience scores.

In the intervening years we have worked with CHRISTUS to implement these solutions at hospital campuses throughout the Northeast Texas region.

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fig. d
Staff shadowing, field observation, artifact collection.
Site assets CTMF fig E
fig. e

“Technically [transporters] are not supposed to go through public places with inpatients, for privacy reasons. But in some places, the only way you can go is through a public passage.” -STF.09


Site assets CTMF PAT03
fig. f

Early morning outpatient appointment ride-along from Nacogdoches to Tyler, TX. (PAT.03)

As the flagship campus of CHRISTUS Health's Northeast Texas region, CHRISTUS Mother Frances Hospital attracts patients from within a 300-mile radius of Tyler, Texas. Many of these patients drive upwards of an hour to reach the hospital and are unfamiliar with the Tyler metro area fig. f.

Because the hospital plans to continue to increase its regional referral network, in the future more and more patients will be first-time visitors from out of town. Our research found that the hospital campus is currently illegible to this demographic of visitors.

One patient we shadowed was a first-time visitor who was referred for an outpatient MRI by her primary care physician in Nacogdoches, Texas—an hour East of Tyler fig. g.

Pat 03 journey
fig. g

“I’m not sure why [my insurance] referred me this far. Nacogdoches has a hospital and everything, and certainly they have an MRI.” -PAT.03

fig. h

PAT.03's campus arrival experience.

The CMFH campus is set up with a clear 'front door' on the West side that borders downtown Tyler, while the East side of the campus offers little signage about parking options and building entrances and feels more staff-facing.

As PAT.03 approached the campus from the East (as directed by her phone’s GPS), she immediately experienced a series of conflicting messages that caused confusion fig. h:

  1. ➀ She was looking for 800 East Dawson (the address written on her pre-appointment letter) but a sign on the side of the hospital building prominently displayed a different address

  2. ➁ Her GPS announced “you have arrived” at the corner of Dawson and Fleishel—before the patient had even seen the front door of the hospital

  3. ➂ Signage for the main parking garage assumed patients would be approaching from the West, and was hidden by bushes and trees coming from the East. The patient completely missed these signs while looking for parking

  4. ➃ The patient also did not see signs for a free surface parking lot across the street and was not aware that there were free parking options available


Site assets CTMF intwayfinding 1 Site assets CTMF intwayfinding 2 Site assets CTMF intwayfinding 3 Site assets CTMF intwayfinding 4 Site assets CTMF intwayfinding 5 Site assets CTMF intwayfinding 6 Site assets CTMF intwayfinding 7
fig. i

“People forget where they’ve been and can’t go back to where they’ve come from.” -STA.15

CMFH is made up of many generations of buildings connected by various hallways and sky-bridges, it reads to patients and visitors as a singular building mass. This is common in most large-scale hospital campuses, especially in cases where there is little to distinguish the interior finishes of one tower from another.

A bland visual landscape without any imageable elements prevents people from being able to build a ‘mental map’ of their surroundings as they traverse the hospital. This makes return-navigating and verbal direction-giving difficult fig. i.

In fact, we found that staff often choose to personally escort guests to their destination rather than attempt to give verbal directions.

In an online survey we conducted of 675 CMFH employees (27% of the roughly 2,500 total employees on campus), 84% said that they escort a guest at least once per shift:

█████░░░░░░░░░░░░░░░░░░░░░░░░░░ 0 (14.79%)
███████████████████░░░░░░░░░░░░ 1-2 (56.07%)
███████░░░░░░░░░░░░░░░░░░░░░░░░ 3-5 (20.56%)
██░░░░░░░░░░░░░░░░░░░░░░░░░░░░░ 6-10 (4.88%)
█░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░ 11+ (3.7%)

While patients and visitors generally responded positively to the personal attention of being accompanied to their destination by a staff member, we found that this culture of accompanying patients ultimately hindered guests’ self-sufficiency and confidence in the space and had a significant negative impact on staff productivity.

ⓘ At 84% of 2,500 total associates, a minimum of 887 labor hours are spent per week escorting visitors to their destinations.


CHRISTUS unit quietness scores anim CHRISTUS unit quietness anim 2 CHRISTUS unit quietness shhh
fig. j
Q9. During this hospital stay, how often was the area around your room quiet at night? [Press Ganey, 110-115.]†

One of the most impactful findings in our research was a correlation between care units bisected by public traffic flow and low HCAHPS scores related to unit quietness fig. j.

Because the cafeteria is on the lowest level at a far end of the campus only accessible by certain elevator banks, the ‘center of gravity’ of public traffic was thrown off and visitors had no choice but to walk through patient care units to reach the cafeteria fig. k.

Without instituting clear wayfinding to direct the public to alternate routes, our research showed that this problem would only worsen with the construction of a new tower on campus.

While the number of responses per unit (n) necessarily varies due to unit turnover, any number of responses above 30 is considered statistically significant for a given date range.

CHRISTUS unit quietness cafeteria
fig. k The most direct pathway from the Cath Lab waiting room (a common point of origin) to the cafeteria goes directly through a patient care unit. In order to avoid this unit, visitors must take a circuitous route with 5 additional turns.


CHRISTUS precaution 1 CHRISTUS precaution 2 CHRISTUS precaution 3
fig. l

"[I'd like to have a precaution sign] that could show or not show multiple options depending on the patient, but that's not getting constantly removed—because they do tear up very easily and we do end up having to make more, like 'I can't find an Accucheck one, I have to go make another one.' And that kind of stinks." -STF.02

As the principal deliverable of the research assessment, FORMATION designed signage standards for a new patient tower at the Tyler, Texas campus that integrates new campus nomenclature while reflecting the updated CHRISTUS brand standards.

A cornerstone of this new system is a custom hybrid patient identification and precaution sign designed to be produced in-house at CHRISTUS' Tyler-based print and fabrication shop.

Existing precaution and patient identification signs were a major pain point for nurses, as the system relied on small strips of laminated colored paper that got easily tattered and often went missing. fig. l

The new signage module eliminates small paper strips, instead relying on a system of active/inactive toggle switches inspired by the familiar gestures of a phone interface. fig. m

fig. m Process documentation: precaution signage module.


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fig. n
The CHRISTUS print shop can now produce signage with raised copy and inlaid Braille beads.

One of our research recommendations was to bolster the hospital’s already capable print shop to produce signs for the entire CHRISTUS system. We advised CHRISTUS on the purchase of two new machines that use state-of-the-art technology to fabricate tactile graphics compliant with ADA standards. fig. n, fig. o

ⓘ This new capability resulted in an 85% reduction in signage maintenance costs.

fig. o Campus signage in production at CHRISTUS' new regional print and fabrication facility in Tyler, TX.


fig. p

Layers of textured dichroic material encourage optimism in the corridor of a Neonatal Intensive Care Unit.

Our strategic master plan set goals for improved campus wayfinding to create imageable spaces for user orientation.

We designed one such space as a donor recognition opportunity that became a reflective and inspirational moment in the otherwise stressful environment of a NICU.


fig. q Audit activities at CHRISTUS Good Shepherd Medical Center (Longview, TX).

In an effort to align the CHRISTUS guest experience across multiple campuses in North Texas, FORMATION developed a transferable solution for room numbering that addresses immediate administrative challenges and anticipates the addition of future structures. We performed a detailed audit of existing signs and room numbers at each campus. fig. q, r

Outcomes include:

  • Frictionless transition to a new electronic health records (EHR) system
  • Eliminated duplication of room numbers across campus
  • Alignment between wayfinding, facilities, and billing room numbers
  • Less destination confusion for guests and staff
fig. r Audit activities at CHRISTUS Good Shepherd Medical Center (Marshall, TX).


  • Philip LeBlanc (president)
  • Lauren Serota (research lead)
  • Ava Burke (research director)
  • Tyler Swanner (design director)
  • Erich Theaman (systems director)
  • Del Shankle (CHRISTUS liaison)
  • Hollee LeBlanc (CHRISTUS liaison)