Three months to change a product concept and increase retention

Two years ago, Urgo came to see us at BAM to create a mobile application for nurses: Healico. The objective was to help nurses do a better follow-up of chronic wounds: wounds that can take several months to heal (such as ulcers for example). If they are poorly cared for, these wounds can become necrotic and lead to amputation. In other words, ​​this application aims to save limbs.

Initially, this application is intended for private nurses delivering at-home care. They generally work in a nurse’s office with one or two colleagues. These nurses do not only take care of chronic wounds but also take medication or draw blood, for example. Regarding patients with chronic wounds, they see them every day or several times a week. And since a nurse is not going to work seven days a week, there will be so-called transmissions between several nurses in the same practice. These transmissions are about how the patient is doing, what is new, and how wounds are evolving. And that's what we want to facilitate with Healico, we want to facilitate communication between nurses to have optimal wound follow-up. Our features revolve around transmission and wound assessment as clues to detect signs of serious infection and better help nurses in their daily work lives.

Healico represents for Urgo a double challenge: creating trust with the nurses and helping them to progress in their practice. Indeed, they have noticed that a large part of nurses, in particular private nurses, tend to stay on types of dressing they know rather than use newer, more effective dressings. It is therefore a real challenge to manage to reach this segment of nurses who, being independent, have fewer obvious resources to self-train. We will therefore also find in the application a section containing articles and answers to questions that nurses may ask themselves.

However, one year ago, the team realized that the application had poorer retention than expected. That is, we had few nurses adding content compared to the total number of users per week. Adding content means adding a photo, a treatment, or a wound assessment. A wound assessment includes a series of questions to describe the appearance of the wound in a scientific way, allowing another nurse to immediately understand the condition of the wound.

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

We started with a twofold observation: first, we have no idea why nurses using the app do not create content or stop using it, and that is because have no contact with them. Second, the team has a detailed knowledge of the parameters that nurses find important to take into account in the follow-up of a wound, but no answers to broader questions such as what selection criteria and preferences come into play when they use a wound transmission and monitoring tool.

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

The first thing we did was conduct interviews to dig deeper into the "job to be done" of nurses. We took a broad interest in their profession, what they find important, and what their best and worst memory are. The idea was to bring out their emotions and put the finger on what is really important to them.

We remained deliberately open to all weak signals, we did not delve into any particular subject to bring out subjects that we had not thought of before. The goal was to be able to see the gap between what we discovered and the product we had created.

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

To give you a few instances, I followed a nurse who used her phone a lot, and for example, to find her patient's building code, she used Siri to look up the patient's profile. Then in the elevator what I noted was a question she asked me “How many patients have we seen already? at least 10 right?” She asked me the same question several times during the tour. Once in the patient's home, I noted that the drugs and care items were in the kitchen when she was meeting the patient in her living room. I noted everything that was related to the actions and emotions of the nurse. Every detail counts, especially since at the end of the tour it is impossible to remember it all, which is why noting everything at this stage is important.

From these encounters, we learned two major lessons: the first is that we observe a huge oral culture rooted in their habits. Indeed, few nurses take notes in the patient's home, and a large number of them make give transmissions to their colleagues orally. When they have questions they will call each other. And what goes hand in hand with this oral culture is an incredible memory. They remember everything! The nurse I followed only looked at her diary once in a seven-hour round (roughly twenty patients). When she met her colleague in the middle of the round, they were able to share information about patients without even mentioning their name, which says a lot about their mutual handle over patient care.

The second lesson, which is a striking realization for us, is that taking a photo today is a simple swipe. And our application was far from this simplicity. Just have a look:

So how to help nurses more effectively in transmission? We for sure won't be able to get the nurses to note everything, so the solution leans towards adding this oral culture in the product, or something else entirely.

Talking with the nurses, we also noticed that they did not always manage to value all their work. Indeed in France, a private nurse is paid for each care act, that is to say that she declares a fixed quotation for each treatment provided (fitting a dressing, changing a dressing, etc.). New quotations were introduced one or two years ago to better remunerate the management of complex wounds – seven times more than other quotations. This new rating can be used once per wound starting with the initial assessment of a complex wound. Each nurse must be able to justify to social security that their assessment was carried out within strict standards with a written record. As the nurses are afraid to mess up this record, they prefer to stay on lower quotations which do not remunerate their work at its fair value.

What becomes clear and exciting for us is that we have an opportunity to help nurses earn a better living if we manage to provide them with an ingenious solution that adapts to their strong oral culture while being recognized by social security. And what is very interesting about this realization is that it highlights a very important point in the creation of a product: that a product is a series of choices, and behind each choice hides a trade-off.

We had made a trade-off in favor of the written record and remuneration of the nurses but we neglected ease of use and their oral culture.

Let’s take a break to take a step back.

What do we learn from this example? In 1 month of Go&See and interviews, we pinpointed multiple crucial elements explaining the lack of content added to our application.

What made the difference between this approach and the first meetings held at the very beginning of product design two years ago? What we observed, the questions we asked, and precisely the questions we didn't ask. Two years ago, we sought to digitize a use by focusing only on the details: the stages of wound care or the questions nurses ask themselves when they carry out an initial wound assessment. Complex. But we missed the framework in which nurses evolve, their habits, and their emotions.

I’m saving the rest of this story for the next article, which will cover what we have changed and the results we have managed to obtain. Be sure to subscribe to be notified when it comes out!

In the meantime, I’ll leave you with this question. On the last time you went to meet your users, what did you observe? What assumptions were you verifying? What novelties did you uncover?