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…
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).
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!