The Boardgame Design Project, Part 5: Making Revisions

It’s been a couple of months since my last article in this series, but don’t think that I haven’t been hard at work on Acute Care!  I did, in fact, take my prototype to MACE.  In all, I got in 3 plays of it there and then another one with Gwen and my brother Tony sometime in the next few weeks.  That may not sound like all that much, but it was certainly enough for me to see some glaring problems with the game and pretty much halt aggressive playtesting until I figured out what to do about them…

Big Problems 

So, what was wrong with it?  Most importatly to me, it was that the “best” way to play the game was to totally ignore your patients, or, even worse, to actively seek to make them worse so you could send them to Critical Care and have more time to spend doing “quality improvement”.  I had some pretty clear design goals for this game, and this really slapped every freaking one of them in the face.

There were also some balance issues with scoring and a number of other things, but until I fixed the main problem of thematic integrity, I couldn’t worry about too much else.
Let’s Make Patients BETTER!

The game had a lot of patient movement, both in discharging and in transferring them to ICU.  As long as discharges and transfers were pretty much equal to the players, I was going to have a problem with them wanting to make patients worse so they could use the transfer action.  What I needed to do was to incentivise discharges and making patients better while making it more dangerous to ignore patients and letting them get worse. 

I started by adding a Quality score gain when you discharge a patient.  Basically, the team will get Quality equal to the patient’s initial Acuity, which means that the sickest patients will give the greatest rewards for being discharged, which makes sense to me.  

Second, I decided to completely eliminate the standard Transfer to CCU action.  But since reality dictates that you can sometimes transfer someone to a higher level of care, I also created a card called “Transfer to Critical Care” that does the same basic thing.  I’ve also got another mechanic in mind that might help to make it even more useful, but I’ll get to that a little later.

The last thing I did to really scare the bejeezes out of players was to officially add a bad penalty for letting a patient rise above 5 Acuity.  Basically, if someone’s Acuity would ever rise to 6 or higher, they die in a way that we could have prevented, and it’s considered a “Failure to Rescue” (which is a real term in hospital quality metrics, of course).  

What is that “bad penalty”, though…         

Clarifying Quality

A few of the playtesters pointed out to me that a lot of times, bad things can’t just be forgotten because you did something good.  It doesn’t matter how good our patient satisfaction scores are if we, for instance,  let someone fall or develop a pressure ulcer or, even worse, die due to being imporoperly restrained.  So there was this idea of a “black mark” that couldn’t be erased floating around out there, which gave me an idea that would change the whole nature of how the game would be scored.

In the first version, I just sort of had this sliding scale of quality that was a big tug-of-war between positive and negative influences.  Now, I still have a limited tug-of-war going on, but it only goes up to +5 or down to -5.  At that point, the score is reset to 0 and the players either get a Deficiency (negative achievement/”black mark”) or a Quality Key (positive achievement).  And the simple implication of this is that at the end of the game, more Quality Keys than Deficiencies means that you’ve “won” the game (and vice versa, of course).

The other thing that I’ve always wanted to include in the game was an “auto-loss” condition, like so many other cooperative games.  For Acute Care (at this point anyway), if you ever get to 5 Deficiencies, you lose the game right then.

And the other thing this let me do is to have cards and effects that not only gave Quality increases or hits, but also directly granted either a Quality Key or Deficiency.  For instance, a “Failure to Rescue” event discards the patient and gives the team a Deficiency.  There’s also a card in the deck called Provide Respectful Care, which gives a Quality Key at the end of the game if that patient never suffers a Complication (which I’ll get to next).       

Getting Complicated

From the very beginning, I wasn’t happy with the random table that I designed to determine what sort of complications a patient might have from not being cared for.  My plan was always to have another deck of cards to govern this, and I finally got around to designing it.

Any patient not being fully cared for on their turn will be dealt one of these Complication cards.  Each card has certain requirements for it to apply, such as a certain Acuity level and/or Keywords (like Cardiac, Geriatric, Surgical, etc.).  If the requirements aren’t met by the patient (a “Surgical” complication being dealt to a “Medical” patient, for instance), then nothing happens.  But if it does match, there will be some sort of Acuity and/or Quality impact. 

In my first version, a nurse would risk only one patient having a complication each turn, regardless of how many patients she didn’t care for.  But with this change, not watching your patients, especially your sicker or more complicated patients, would always run the risk of them having something bad happening to them.  Again, the goal was to tie more of the players’ time into doing things that nurses really do, and I think this might just work.

Was that all?

Actually, no.  There were some other things that I put into place and changes that I made, but I think this is enough for now.  Again, the goal was to create a realistic nursing-themed game that required cooperation, and I really hope that these decis
ions will continue to push it in that direction!

The Boardgame Design Project
The Boardgame Design Project, Part 1: Design Goals
The Boardgame Design Project, Part 2: Brainstorming Mechanics
The Boardgame Design Project, Part 3: Wrapping up the Conceptual Phase
The Boardgame Design Project, Part 4: Prototyping and the First Playtest!


  1. I’m really becoming more intrigued by this game concept as you flesh it out. How do you motivate the Hippocratic Oath in a game? Pandemic makes it really bad to neglect any one part of the world in favor of another or in favor of focusing too much on researching cures and not enough on treating infected cities.

    Great stuff. I like how you’re thinking in terms of constructing the game to motivate decision-making consistent with the theme.

  2. tomg

    I’m really interested to try the new version. I thought the first was pretty good. The changes sound pretty cool and fit what you had explained you wanted the game to represent.
    Let’s play soon.

  3. Chris Norwood

    Thanks for so clearly describing what I’m trying to do!

    I mean, I certainly want to create a fun game to play, but I won’t be happy with it until the experience it delivers comes pretty close to the reality of what nurses actually do.

  4. Sounds like an interesting game Chris. You should try to get your hands on a copy of Field Hospital.

    Its designed by my friend CW and should be available on The Game Crafter. I haven’t heard it from the horse’s mouth so take this with a grain of salt: I think Field Hospital is being picked up by a publisher and will be due to be out later this year.

  5. Chris Norwood

    I’ve heard about Field Hospital a time or two before, but never had the chance to see it in person.  Maybe I just need to go on and order it myself from The Game Crafter…

Comments are closed.