Healico: why and how to make gemba

Today it is common knowledge that to build a good product you have to meet its users, talk to them. Everyone is talking about discovery, every good self-respecting product manager and designer has already done user interviews. However, not all products are a success. But why since we went to see our users? The difficult thing is to be lied to. Our users are lying to us; and not only are our users lying to us but we are also lying to ourselves.

The cause? As human beings we are all subject to a multitude of biases.

When we interact with another person, for example in an interview, the way in which we ask the question, the way in which our interlocutor answers us and the way in which we interpret the answer, are subject to bias. So in addition, when you have an idea for a product that you are excited about, it is almost impossible to avoid bias! How can you avoid falling into these traps and untangling what's true from what's false?

Rob Fitzpatrick has written an interesting book on how to avoid interview bias, The Mom Test. But the best thing is still observation. Where observation makes the difference is that the eye is the only organ that does not lie. What is observation? How do you do it well so as not to fall back into the same pitfalls as interviews? I suggest that you answer these questions by sharing what we have learned and done with one of our customers: Urgo.

3 years ago, Urgo came to us at BAM to create a mobile application for nurses: Healico. The objective is to help nurses better monitor chronic wounds: wounds that can take several months to heal (such as ulcers for example). If improperly cared for, these wounds can necrotize and lead to amputation. The idea of this application is therefore to participate in saving members. Before getting to the heart of the matter, let's start with a bit of context about the product itself.

A bit of background on Healico

Initially, this application is intended for private home nurses. Home nurses usually work in offices where there are 2 or 3 of them. These nurses not only take care of chronic wounds, moreover, but also of taking medication or blood tests for example. But when it comes to patients with chronic wounds, they see them every day or several times a week. And since a nurse is not going to work 7 days a week there will be what we call transmissions between several nurses in the same office. They transmit information on the patient's condition, news and how the wound evolves.

And that is why Urgo decided to act with Healico. Facilitate transmission between nurses for optimal wound follow-up. In Healico, we will therefore have functionalities that will revolve around transmission but also on the wound as clues to detect signs of serious infection and better help nurses in their daily lives.

The impact of biases

But now, 2 years ago, the team realized that the application had much less retention than expected. That is, compared to the total number of users, per week, we had few nurses who added content. The addition of content is the addition of a photo, treatment, or evaluation of a wound. A wound assessment includes a series of questions to describe the appearance of the wound in a scientific manner, which allows another nurse to immediately understand the condition of the wound.

We then enter a critical phase where, with Urgo, we give ourselves 3 months to improve this retention. I then joined the team to create the task force responsible for solving the problem.

The solution: Gemba, but not just any other way

We start with a twofold observation: first, we have no idea why nurses using the app don't create content or stop using it because we don't contact them. Second, the team has a detailed knowledge of the parameters that nurses find important to take into account in wound monitoring but no answers to more macro questions such as what are their choice criteria and preferences that will come into play when they use a wound transmission and monitoring tool.

So we made the decision to return to the field with a fresh eye this time.

1- Digging out the Job To Be Done

The first thing we do are interviews to further explore the “job to be done” of nurses: we therefore took a very broad interest in their profession, what they think is important, what are their best and their worst memories. The idea is to bring out emotions and to put your finger on what is important for them.

We deliberately remained open to all weak signals, we did not delve into a particular subject in order to bring out topics that we had not thought of before. The objective is to be able to see the gap between what we discover and the product we created.

2- Do Go&See, go out in the field

The second thing we did, and in my opinion the most important thing because it was the richest in learning, were Go&See. Doing a Go&See is going to see the user where he is using the product or where he observes the problem that we want to solve. So we went to follow 4 nurses during their patient rounds. The tricky thing about Go&See is that you will observe, discover and understand a lot of things and at this point everything is important. It therefore requires a real work of attention to detail and note taking.

What we've learned about our nurses and our product

To give you a few things, I followed a nurse who used her phone a lot, and for example, to find the code of her patient's building, she used Siri to search for the patient's profile. Then, in the elevator, what I noted was a question she asked me: “How many patients are there now? At least 10 no?” This is a question she asked me several times during the tour. Arriving at the patient's house I noted that the medications and treatments were in the kitchen while she had to meet the patient in her living room, I noted everything that was related to the actions and emotions of the nurse. In short, all the details count, especially since at the end of the tour it is impossible to remember all the details, which is why it is important to write everything down at this stage.

From these meetings we have drawn 2 major lessons: the first is that we observe an enormous oral culture rooted in their habits. Indeed, few nurses take notes on the patient's home, and a large number of them make oral transmissions to their colleagues. When they have questions they will call each other. And what goes hand in hand with this oral culture is an incredible memory, she remembers everything: the nurses I followed only looked at her agenda once in 7 hours of tour (~20 patients), when she met her colleague in the middle of the tour they were able to share information about patients without even quoting patients because they knew each case and wound in detail.

The second learning, which is more of a realization, is that today, taking a photo is a swipe. And with the application we created we were far from this simplicity.

So how can we help nurses more effectively in transmission? whether by adding speech to the product or something else, but we won't be able to get nurses to write everything down.

And on another subject, talking to the nurses during their tours, we noticed that they were not always able to value all of their work. In fact, in France, a private nurse is paid on a fee-for-service basis, i.e. for each treatment provided (applying a bandage, changing a bandage, etc.) she declares a quotation. A new listing was created 1 or 2 years ago to make it possible to better pay for the management of complex wounds. This new rating can be used once per wound at the beginning of its treatment, it is the initial assessment of a complex wound. However, this rating allows to earn 7 times more than the other ratings, each nurse must be able to justify to social security that the assessment was carried out in accordance with standards with a paper trail. And since nurses are afraid of not having all the written information necessary to justify this act, they prefer to stay on lower quotes that do not pay their work at fair value.

What then became clear and exciting for us was that we had an opportunity to help nurses earn a better living if we could provide them with an ingenious solution that adapted to their strong oral culture while being recognized by social security.

At this stage I hope that you are now all convinced that going to observe your users in their context is essential! In any case for our part, since then Go&See have been an integral part of almost all our discovery.

Go&Sees are all the more important because making a product means making a series of choices, and that behind each choice there is a trade-off. To identify the trade-offs we are doing, it is necessary to have a deep understanding of what is happening with our users! In our case with Urgo our Go&See allowed us to put our finger on an interesting trade-off:

On Healico we had made a trade-off in favor of the written record and remuneration of the nurse despite the simplicity of use and her oral culture.


In 1 month of user meetings, we identified several crucial elements that explained the low written use of our application.

What made the difference between this approach and the first meetings made at the very beginning of product design 3 years ago?

What we watched, what questions we asked, and more specifically what questions we didn't ask. 3 years ago, we tried to digitize a use by focusing only on the details: the stages of wound management or even the questions that nurses ask themselves when they carry out an initial assessment of a complex wound. But we missed the framework in which nurses operate, their habits, their emotions.

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