Case study: journey mapping in healthcare
This case shows how the Community Empowerment Lab, a global health research and innovation organization, used Smaply to help design a model for scaling Kangaroo Mother Care in rural India.
The project team succeeded in involving all necessary parties to work together and better understand each other’s motivations and needs by analyzing their stakeholders’ and their patients’ journey. The project was selected as a national best practice in July 2017.
About the organization
Community Empowerment Lab (CEL) is a leading interdisciplinary global health research and innovation organization financed by the World Health Organization (WHO), embedded in rural Uttar Pradesh state in northern India.
CEL has extensive expertise in scientifically robust design and evaluation of neonatal, child and maternal health intervention models. They scaled their work through health systems based approaches as well as alternative approaches such as self-help groups and social enterprises. CEL scientists have done seminal work on community-centered design, behavior change management, child survival and development, Kangaroo Mother Care, health system interventions and technology-driven assessment methods. These programs have informed global policy and spurred scientific research and program development for developing country settings across the globe.
Uttar Pradesh as the largest state of India is facing serious health problems and can be considered as the epicentre of global health challenges. While health facilities are acceptable in urban areas, rural areas often lack proper health infrastructure and there are no standardized processes for the use of health facilities. Another big challenge is there is some mistrust towards health institutions.
People don’t need messages, they don’t need information — they need a friend they can trust. If you go and tell them something, it doesn’t change anything. You need to work with them. There is no shortcut to these things — you need to navigate, negotiate. You need to nudge.
Vishwajeet Kumar, Founder and CEO of CEL
In 2016, 200,000 newborns died in Uttar Pradesh. A quarter of these could be averted by the Kangaroo Mother Care (KMC), a method of care that considers skin-to-skin contact and breastfeeding essential for newborns. It mainly targets preterm born (under 9 months) and under weight (under 2,000 gram) babies and fulfils the fundamental needs of every newborn: love, warmth, food and protection. Medical studies prove that KMC is the most powerful intervention for reducing mortality in low-birth-weight infants, effective in 40% of the cases, however only 1% of newborns worldwide are actually receiving KMC.
Aim of the project
The Kangaroo Care Project is a joint collaboration between the National Health Mission and the CEL. It aims to develop, test and scale models for KMC by gaining an understanding of the impediments and potential facilitators. KMC’s approach to scaling and improving their work draws on repeated rapid cycles of model development – implementation – evaluation -refinement until it finds promising models to achieve high coverage. The team will pilot-test the models with the ultimate aim of successfully providing KMC to 80% or more of the target population of newborns, aiming to reduce mortality associated with preterm birth and infections.
CEL wants to design an ecosystem that promotes the uptakeof KMC using principles of design thinking, systems dynamics and implementation science. Hence, CEL decided to document the patients’ and other stakeholders’ journeys and design improvements for them.
The project- and a research team decided to follow a holistic approach in order to improve the experience of mothers and their babies. Therefore, diverse groups were included in this process: health facility staff, mothers, data collection teams, the design team and a formal research team. All of them provided input for the creation of stakeholder maps, personas, and journey maps.
CEL looked for a tool that would allow them to scale the project in the future and decided to go for Smaply because it enabled them put into practice the following planned process:
- Stakeholder mapping should help gain an overview of the stakeholders involved.
- Creating personas was supposed to create empathy with the stakeholders.
- Visualizing the mothers’ and other stakeholders’ journeys was expected to help discover pain points and points of opportunity.
The first step was to identify all the stakeholders that might be involved in the implementation of KMC. This helped the internal team understand who plays which role in the journey. The project team therefore first created a stakeholder map to map out all relevant stakeholders like mothers, government officials, nurses, midwives, doctors, community health workers, husbands, mothers- and fathers-in-law.
The CEL team gave printed stakeholder map templates to the project team in order to provide them with a structure on how to get started. The project team could map stakeholders themselves and understand who plays which role. An example of an initial stakeholder map of a nurse from the KMC lounge in the district women’s hospital was as follows.
In a next step personas were created for these stakeholder groups. Creating personas helped the project team understand each stakeholder group’s background, motivations and challenges.
The persona development started with data collection through various methods, like observations and interviews with mothers, nurses, doctors, and accredited social health activists. This process helped to understand the perceptions or motivations of a stakeholder, what factors in their life
are responsible for a certain behavior and how to then start to influence this behavior.
Finally, based on the stakeholder maps and personas, journey maps were created for the key personas. The journey maps specified each stakeholder’s experience and described in detail what they were going through in the health facility, also on an emotional level.
- One journey map focussed on the mothers’ experience, more precisely of a mother giving birth in rural areas -from entering the facility, giving birth until leaving again.This journey map included information about the health facilities in the area, the birth itself and the following four to five days stay within the health institution and the treatments that both mother and child receive afterwards (e.g., vaccinations). The questions to be clarified were: Which touchpoints were identified, where is she lacking respectful care and what emotions is she going through? By using text lanes the daily routine of nurses were described as well as their feelings toward different people, things and processes. Furthermore storyboards were added to each touchpoint as well as an emotional journey.
- The team sought to understand the journey of a KMC nurse in the health facility. As nurses are the primary caregivers in the facility, they play a very important role in ensuring that mothers can successfully provide KMC to their newborns. Through journey mapping the team sought to identify the motivations, enablers and barriers that influence a nurse and what were the key areas where intervening might help positively change her behavior so that the mother and newborn can be cared for well.
Insights and implementation
The project team learned several lessons resulting from this process and generated the following main insights:
- The emotional level and thus empathy is a key success factor – nurses showing empathy for mothers, doctors showing empathy for nurses. In order to make change happen creating empathy has to be done step by step and with the involvement of the local community. This can then impact others behaviors and strengthen the health system.
- The insights from creating stakeholder maps, personas and journey maps resulted in ideas to improve the problems identified, which were then implemented by new products and processes to create better services and understanding.
- Through the journey mapping process the team realized that nurses play a crucial role in ensuring the success or failure of KMC adoption in the health facilities. The experience of the mothers in the KMC Lounges within the health facilities is furthermore crucial in ensuring higher rates of KMC being provided to the preterm and low birthweight newborns at the facility and at home. Hence, CEL decided to create a team of nurse mentors who are led and trained by Dr. Barbara Morission, one of the world’s leading experts on KMC, newborn care and breastfeeding. In a special workshop she tried to address barriers which were identified at the earlier stage and which prevented the successful adoption of KMC in order to overcome those. Also during these trainings personas were created and in order to understand the needs and problems of nurses, their daily journey was mapped.
- This team’s work started in autumn 2017 and it is expected to be an important part of the larger KMC scale up efforts happening in the state of Uttar Pradesh.
- It works hand in hand with the nurses in different health facilities where KMC Lounges exist, so that they can become capable of both understanding the importance of KMC, empathizing with the mothers and newborns and facilitating this natural process in the best manner possible.
To successfully implement KMC, the project team had to understand the behavior of many key stakeholders. Through the use of stakeholder maps, personas and journey maps, the project team could answer important questions like: What experience do stakeholder groups go through? At which point of their journey do they need help? Where are interventions needed? Gaps within the service delivery were therefore identified and could be tackled by providing solutions. The project has been scheduled to continue till June 2018 by which time successful models for scaling KMC would have been developed.
One of the key challenges for us over the last 14 years of working in Uttar Pradesh state has been that of systemizing learning, to find tools to democratize this learning process. Tools like Smaply allowed us to finally democratize the process of understanding end users. When a young woman from a small village who does not speak English and did not go to Harvard, can use journey mapping and bring value to her community, then you know that you have been able to democratize the process. All stakeholders involved in this project succeeded in under- standing other people through the use of the tool.
Aim of the project: To reduce newborn mortality in Uttar Pradesh by scaling KMC
Number of personas created: 10
Number of customer journeys created: 12
Number of stakeholder maps created: 5