1. Getting started with Metro Mapping

In this module the Metro Mapping method is explained. The project approach, the phases, the tools, including the Metro Net and Metro Map, and the team members are discussed.
Table of contents

1.1 Introduction

Metro Mapping is a service design method to design and optimise care pathways. Metro Mapping can be used to improve patient experience and help with clinical challenges, such as implementation of shared decision making, creation of patient value and improvement of multidisciplinary cooperation.

A Metro Mapping project starts with mapping the current care path and the needs of stakeholders (care providers, patients and relatives and other stakeholders). The care path and the insights are visualised as the Metro Map 'as is'. The care path is then optimized or (re)designed together with stakeholders. This is visualised as the Metro Map 'to be'. The Metro Map 'to be' forms the basis for the realization and implementation of the optimized care path. Examples of improvements are: better overview of the care path and care options, improved information access, improved collaboration between teams and with the patient, and optimisation of spaces.

Metro Map as is
  1. Plan of action
  2. Analysis of the current situation
  3. Inventory of stakeholder needs
Metro Map to be
  1. Co-design sub-solutions
  2. Integrated solution
  3. Briefings for implementation
Metro Map realised
  1. Realisation

1.2 Analysis

The Metro Mapping method aims to contribute to the improvement of healthcare. Before starting with the analysis of the current care path, it is important to determine the goal of the improvement and the scope within the organization to realize this. The Metro Team will also be assembled and the plan of approach will be developed. After this, the current care path and the needs of stakeholders are mapped out in the Metro Map 'as is'.

1.2.1 Plan of action

Goal and scope

A meaningful project to improve starts with a good picture of the goal and the scope. This helps in the next steps, including retrieving the right information and involving the right people. In addition, it helps to check during the project whether the project is still moving towards the intended, meaningful result.

Often one or more goals have already been formulated before the start. Discuss with each other whether everyone has the same view of the goal. For example, different people may have different ideas of what 'joint decision-making' is. The available scope can be about the development budget and the lead time of the project. I could also be about for example, which departments and organisations are involved and what the (financial) scope is for the implementation of improvements.

It helps to properly record the goals and scope and to regularly evaluate the interim results and progress.

The list of in-depth questions below can help to clarify the picture of the desired improvement and the scope.

  • What is the desired improvement? Do we mean the same thing and do we all support it?
  • What is the reason to want this improvement?
  • For which condition (and stages of that condition) do we want to use Metro Mapping?
  • Which patient group(s) are involved and how large is each group?
  • Which functions, departments and other organizations can and do we want to involve?
  • Are there guidelines that we must comply with?
  • Are there quality marks that we want to comply with?
  • What is or is not possible with regard to solutions, for example: would renovation be possible?
  • Are there preconditions with respect to, for example:
    • Budget
    • Lead time
    • Legal Affairs
    • The organization (who decides what)
    • Context (e.g. the building)
    • Health insurers
    • Different interests of the healthcare organisations involved
    • Integration with EPD and other information systems
    • Integration with the quality system
    • (Clinical) research
    • Other, time consuming projects
  • Are there healthcare institutions or healthcare networks that we can learn from?

Metro Team

The Metro Team is the core team that carries out the project. It consists of the functions required throughout the project:

  • Service designer(s), who execute the project according to the Metro Mapping method.
  • Healthcare professional(s), who have knowledge of and experience with the healthcare pathway.
  • Care management, who can co-decide on the goals and scope and the connection to other developments in the care organisation.
  • Project coordinator(s), who arrange matters concerning the project.

This core team can choose to involve additional expertise when necessary, for example from the communication, quality and safety, IT and facility services. And they can involve stakeholders from outside their own organization, such as patient associations and (regional) partnerships.

Further definition of steps

The Metro Team further defines the steps in the Metro Mapping method together. For example, how many and which patients, relatives and healthcare professionals will be involved. The Metro Team also determines how the stakeholders can best be involved, for example via an online questionnaire, interview or group discussion.

The Metro Team also ensures that those involved and the client(s) are informed about the progress of the project. The Metro Team informs those involved about the opportunities for improvements and selects the most promising improvements that match the goal and the space within the organization.

1.2.2 Analysis of the current situation

Care pathways are often so complex that no one oversees them completely. The visualization of the current situation provides an overview and helps to discuss needs and improvements. 

Two visualisations are used within the Metro Mapping method; the Metro Net and the Metro Map.

The Metro Net provides high level insight into all research and treatment options for a condition. The Metro Map shows a specific care path within all these research and treatment options. The Metro Map is structured in such a way that it provides insight into the four themes that are important to the patient in promoting shared decision-making; the steps in the care path, the information given to the patient, the healthcare professionals involved and the environment in which the care takes place. Parts 2 and 3 of this manual explain which information is visualised in the Metro Nap and the Metro Map. Read these parts before you start taking with the analysis of the current situation.

Metro Net

Metro Map

First sketch

It is useful to first make a sketch of the Metro Net. This can be done, for example, with the input of a small number of care givers and information sources such as patient leaflets, websites and guidelines. Another way to make an overview is to retrieve data from the EMR of a number of 'typical' patients. In the beginning it often works well to draw a Metro Net on paper. When there is a good first draft, the sketch can be drawn in Microsoft Visio.

It is also useful to start with a sketch when making the Metro Map . After this, the details can be added. Detailed information can be retrieved in various ways, such as interviews with patients, relatives and care givers or by following along and observing. The Metro Net and the Metro Map provide structure to the conversations.

Goal determines content

The goal of the Metro Mapping project determines which care path is elaborated in the Metro Map and at what level of detail. Determine with the Metro Team which care path will be mapped out, for example only the curative treatments, or only for a specific type of condition. Also determine whether experimental treatments are included. When elaborating the Metro Map only those steps are shown that are relevant to the purpose of the Metro Mapping project. Depending on the purpose, you can, for example, choose to display the administration of medication, but not to display the ordering, preparation and checking of the medication.

The patient is at the centre of the Metro Map. That is why, at least all touch points relevant to the patient are recorded. Every point of contact between the healthcare providers and the patient and relative is a touch point. If necessary, this can be expanded with digital touch points of the healthcare organisation.

Broad inventory

Because care paths are so complex, care providers often have insight into part of the care path. That is why it is important to talk to a good representation of healthcare providers. It helps to present a draft version of the Metro Net or the Metro Map so that one can add what has already been mapped. It is possible that this leads to conflicting ideas about the care pathway. For example, about which specialist is ultimately responsible for the care of a patient in a certain phase. Discuss this with the healthcare providers involved.

During the inventory of the care path, bottlenecks and requirements are often discussed. Write these down and use them in the next step. 


Transfers from one phase in the care path to the next can be experienced as difficult by patients and relatives. People are faced with a new phase in treatment and different needs, sometimes with different care providers, a different environment and new information. Analyse the transitions and the associated transfers so that it is clear to the patient and the care providers how the continuity of care is guaranteed. 

1.2.3 Inventory of stakeholder needs

In this phase, needs are inventoried among patients, relatives and care providers. The goal of the project determines the approach. The visualizations can help with the inventory.

In order to improve the care path, it is very important to learn from patients and relatives what their beautiful moments, but also frustrations, needs, wishes, concerns and energizing moments have been. The experiences of patients and relatives are added to the Metro Map in the layer above the current situation. This clarifies the connection between the experience and the care pathway. 

Patients' experiences with their condition are about much more than the treatment and support they receive from a healthcare team in a hospital. It can also be about dealing with the consequences of being ill and being treated. Or just about the experiences after the treatments. When making an inventory of the needs of patients and relatives, you should again consider the goal and scope defined at the beginning. 

It is also useful to discuss with care providers what their needs in the care path are. They may experience bottlenecks and frustrations and may have ideas about how the care pathway can be improved. These issues are displayed on the Metro Map. 

Only the needs that are relevant to the goal of the Metro Map and fall within the scope of the project are displayed. It can be useful to record other needs elsewhere, for example to reconsider the goal and the scope or as input for another improvement project.  

The end result of this step is the Metro Map 'as is' with the needs of stakeholders. 

Different way to retrieve requirements:

  • Interviews
  • Questionnaires
  • Sound board groups of healthcare institutions or patient associations
  • Reviews or complaints received by the healthcare institution
  • Social media

Patients and their loved ones can feel powerless, afraid or dependent on healthcare professionals during the diagnosis and treatment process. That is why it is very important to provide security during the needs assessment. Tips to increase the feeling of security:

  • Do not hold conversations with patients and their loved ones together with healthcare professionals
  • Explain that information will be made anonymous: practitioners will not be told who said what
  • Explain to them that they can stop at any time and that if they decide to stop the data will not be used and will not be stored.
  • Let them decide where the conversation takes place (at home or a quiet space elsewhere)

1.3 (Re)design Metro Map

Together with stakeholders, a new care path is being designed in the form of a Metro Map 'to be'. 

1.3.1 Co-design sub-solutions

Sub-solutions are mapped out for each need together with patients, healthcare professionals and other stakeholders.

Sub-solutions can be a development or adjustment of, for example, steps in the care path, digital or physical aids or even spaces or routing in the building

Sub-solutions can be devised in many different ways. For example, by brainstorming with different stakeholders or involving experts. It is of course also possible to look at other departments or other healthcare institutions to see how bottlenecks have been resolved there. 

Mapping sub-solutions together with stakeholders has both content and project-related advantages. In terms of content, the stakeholders understand the need and can quickly oversee the advantages and disadvantages of a solution. Because stakeholders are involved in the development, they are more likely to accept a chosen solution. Evaluating sub-solutions contributes to gaining insights and improving the solutions themselves. 

This step also checks whether the solution directions fit within the scope for improvement.

1.3.2 integrated solution

It is important that the sub-solutions together form a coherent and consistent solution that achieves the predetermined goal. 

In this step, the Metro Team examines which partial solutions can be combined into an integrated solution. The touch points are coordinated. For example, it can be confusing for a patient if he or she receives a paper leaflet one time and then a digital leaflet, but also if contact takes place by telephone one time and by e-mail the other time 

But it is also important for care providers that the solutions meet their needs. Ideally, their work will be easier and more fun and it will not unintentionally lead to more administration. 

By incorporating the proposed integrated solution into the Metro Map 'to be', it can be evaluated with stakeholders. Where possible, the future care path, or parts of it, are tested at an early stage.


1.3.3 Briefings for implementation

In order to be able to implement the new method, the Metro Map 'to be', the sub-solutions will have to be realised. In this phase, the input for the development is drawn up.

1.4 Implementation

In this phase, the sub-solutions are realised, tested and implemented.

The implementation is not discussed in detail in this manual. The realisation of sub-solutions are projects in themselves. The role of the Metro Team is to keep an eye on individual developments and to ensure that they collectively contribute to the stated goal.

Service design

Service design is a field within design in which not one product but complete services are developed (or existing services are improved). Service designers work in the design process together with customers and the service provider. They use design methods to develop solutions for everything that is involved in service provision: the contacts between customers and service provider, the process and also all kinds of information and products that are used in the service provision. Service design is used to develop a user-friendly and consistent service that contributes to a predetermined goal.

Metro Mapping is a service design method with which care paths are (re)designed. A care path is the service that arises between a care organization and patients. Metro Mapping is being developed to support shared decision-making in a care path.