Tools at Work: Perception Mapping in Guatemala

We used perception mapping as a tool to engage, understand, and identify the components of a patient’s experience at Obras Sociales del Santo Hermano Pedro hospital during Operation Walk Pittsburgh’s 2019 medical mission trip. 

Perception mapping is a tool that is used to understand how we believe a process works and how those preconceived notions can impact where improvement efforts are concentrated. Typically, changes come about in healthcare after poor patient satisfaction scores, low patient retention or financial issues emerge. In an effort to bring a hospital, practice or process back on track, stakeholders often take an anecdotal, bird’s eye view of a process and recommend changes based on where they assume pain points exist. These assumptions can lead to changes or costly improvement efforts that don’t actually work. However, understanding these assumptions is key to addressing misconceptions about a process or experience. Leadership may assume a process works in one way and care providers actually *know* that it actually works in a completely different way. Therefore, perception mapping is crucial to the improvement process and most importantly, breaking down silos within an organization.

I arrived in Antigua with a set of assumptions about the continuum of care in a third world country and certain perceptions regarding patient and staff experiences there. I quickly realized that my understanding of clinical flow and processes was deeply rooted in my experiences and shadowing work in the United States. From the open-air Guatemalan hospital with its crowded courtyards to small operating rooms and close quarters, I learned that cultural norms play a large part in patient experience and staff satisfaction, far more than fancy buildings and advanced technology ever will. As I adjusted my expectations and started to shadow over the course of the week, a few segments stood out. They each illustrate the power of perception vs. reality and how perceptions, even incorrect ones, can be used to improve or understand the realities of patient care.

Clinic

Perception: 
With more than 80 patients expected to arrive on a given day, I was skeptical of how the open courtyard would be utilized. Would it be crowded? Noisy? I assumed that with such a high volume of patients arriving each day that confusion would cause tensions to rise. I imagined dissatisfaction due to long wait times and chaos for the four teams who would be evaluating the cases. 

Reality:
While wait times did extend well beyond average wait times in the US, patients at Las Obras remained positive and patient. Many brought multiple family members and the open courtyard gave people the ability to interact, share stories and snacks. Having the Operation Walk Pittsburgh patients all arrive on the same day and time served two purposes, eliminating the financial burden of requiring patients to return to the hospital for multiple visits and ease of communication/group education. For many patients, getting to the hospital in Antigua meant traveling more than 8 hours by bus. Infrastructure and transportation limitations make travel very difficult meaning that patients appreciated the ability to arrive well ahead of their procedure to get settled and make arrangements for the next few days.

Day of Surgery (Pre-Op, Surgery, Pacu)

Perception:
The hospital facility in Antigua has all of the same day of surgery experience segments you would expect to see in the US facilities. However, the rooms for pre-op, surgery, and PACU were very small and very close to one another (too close, in my opinion!). I believed that could cause confusion amongst teams who are working with different patients. The close proximity could cause congestion, delays, and lead to possible mixups with so many staff members working in such limited space.  

Reality:
The proximity of the surgical rooms allowed for efficient communication between the teams. This aided in our team dynamics with the ability for increased communication and created palpable energy from all the action. The confined spaces actually enhanced the ability to communicate and removed the traditional silos that can cause delays in surgery.

Floor

Perception:
One of the most glaring differences I noticed when assessing the patient wards was the lack of an Electronic Health Record at Las Obras.  I assumed that with at least 10 patients per ward, keeping track of accurate paper charts would be confusing, and would lead to the possibility of increased error. I also predicted that the ward style rooms would limit patient privacy. Certainly, this was a major difference between the Guatemalan hospital system and the hospitals and facilities we have here in the United States. I wondered if the communal space would create a lack of individualized care for each patient as they recovered from surgery.

Reality:
To my surprise, the large, ward style rooms created an incredible sense of community amongst the patients and their families. During physical therapy, patients would encourage one another and would celebrate each other’s success as they began to walk for the first time with their new implants. Visiting family members would check in on those patients who didn’t have visitors and it was not uncommon to hear peals of laughter coming from the patient wards. For the nursing and PT staff, the wards were an efficient way to provide care for multiple patients at once, even with limited resources. The community feeling in the room meant that nurses, therapists, and translators all became part of a large extended care family.

Finally, I noticed that while we are dependent on EHR systems in the United States, the electronic records were rarely, if ever, missed. Their absence meant that nurses and doctors had more face time with patients, forging deeper connections.

This perception mapping experience taught me a lot about my understanding of how similar processes work in different countries and cultures. Overwhelmingly the patients in Guatemala had similar outcomes to those in the US. They left the hospital happy and healthy, ready to start their new lease on life with their new joint. Where I had assumed bottlenecks or confusion would occur turned out to be assets to the team environment. The culture of community and cooperation in Guatemala also played a large part in understanding their different medical models. Perception mapping is one of my favorite tools to improve processes and patient experience. It truly shows how our assumptions can inform change and how much we can learn from medical cooperation.

In the next newsletter, I will share what I learned from shadowing their full patient pathway and which processes we implemented to streamline care even further. For questions about this exercise and shadowing, email hannah@goshadow.org.