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What’s your mental map of the world? Do you imagine countries as jagged shapes, in pastel colours with printed names? Or do you envisage a panoply of people and landscapes? Do you hear the local music and language, and smell the food? And is your picture based on books and movies, or firsthand experience?
Europeans often criticise Americans for mixing up, say, Slovenia and Slovakia. But how many of those critics could correctly name and label all the US states?* Perhaps, though, you’re a seasoned traveller, with a Google-map brain. Yet how would you fare on French literature? Or astronomy? Or the Icelandic legal system?
We’re all trapped in our own bubbles. We know this from the polarised reaction to world events, such as Brexit and the election of Donald Trump. But how often do we consider that all our colleagues or clients also carry around different mental maps of how things should be done?
What I personally don’t know literally fills libraries. (And I don’t use the word literally lightly.) But that’s true for all of us. The last person to have read every book in existence was supposed to be Samuel Taylor Coleridge. Even in the 19th century, though, with millions of books in print, that was a patent exaggeration. No one can have read everything. And no one knows everything.
Our mental maps (or models) are vital in helping us sort what we know into categories we can access. Most of the time we can get by well enough with the knowledge we have. Until we can’t.
So in a world where everything seems to be moving faster, how do we keep up with new ideas? And do we even need them? Don’t the old ideas still work?
The short answer is ‘no’.
“We can usually get by well enough with the knowledge we have.
Until we can’t.”
With challengers nipping at your coattails—if you’re leading the pack—or a competitor threatening to jump to light speed and leave you for a different galaxy entirely, taking your customers with them, you need to transform your approach. The capability to do more, with the same or fewer resources, and do it faster and more reliably is a necessary condition for sustainable success. But it’s not sufficient.
What work really matters?
At some point, surely, we’ve all had a niggling feeling that there must be a better way of working. Unfortunately, we’re stuck on the treadmill with seemingly no time to stop for breath and look for better approaches. Also, it’s hard to know which ideas are worth our time, when so many people seem to be selling snake oil or the latest management fad. How to know where to leap?
This article already has a lot of questions. And with reason; we believe that a powerful question is more than half a good answer. So let’s start with the fundamentals: Where are we going? And how will we get there?
Think of the answers first in terms of your organisation and the part of it that you contribute to; then also as they affect your personal career ambitions. If you’re going to take a bold step, the two elements—organisational and personal—must be intertwined.
Start with your organisation’s goal. We call ourselves Ensemble because we understand that an organisation is like an ensemble of musicians. The orchestra convenes with a goal in mind: to perform the composer’s music for an audience of listeners. In the analogy, the audience is your customers or clients and the orchestra your organisation’s employees. The music is the strategy the composer (the boss!) has decided to follow.
But an orchestra also needs a score which breaks up the whole piece of music into parts for strings, woodwind, brass and percussion. There are ‘sections’—the first and second violins, for example—with further specialists on piccolo or harp. Without individual written parts, these players would be making up the notes as they went along, hoping to play in the same key and start and finish at the same time.
Even with written parts, the orchestra needs a conductor, otherwise the players won’t play in time or blend their sound into a unified whole. Conducting involves rehearsing (planning) and performing. We call this ‘work management’ and we can give you the tools and capability to do it better. But let’s take a step back for a moment to the goal again.
We take the whole—the desired resulting ‘performance’—and apply ‘systems thinking’ to make sure that everyone in the ensemble understands the goal and how their role influences it. The piccolo player may only have (ahem) a small part, but when he plays, the whole audience can hear. He’s vital to the success of the project. Every project has performers who are only required for walk-on parts. How you manage the scheduling and resourcing of these roles can dramatically change the overall success of your organisation.
What’s holding you back?
It’s become a truism that the world is ever more connected, with global markets and the instantaneous transmission of information. A change in the weather or a political coup can easily scupper supply chains. We can’t predict or affect these things, although we can account for some of the risk in our planning. Instead, we start by examining our sphere of influence and span of control. That will tell us the extent of the system that we can manage. Many clients are surprised when they consider how much they can control if their organisation works in concert.
“A powerful question is more than half a good answer.”
Yet it’s surprising how many organisations still work in silos. Each division or department—or even team within a department—has its own ‘key performance indicators’; information and personnel are not maximised and rarely shared. The law of unintended consequences means it’s possible to optimise at this level to the detriment of the system as a whole—the equivalent of the brass instruments playing too loudly; they may sound beautiful, but they drown out the strings who happen to have the tune.
So in complex systems, we seek out the interdependencies. We need to dig down to identify root causes and envisage the effects that our work will have—both desirable and undesirable. Then it’s about managing the work. Peter Drucker said that ‘management is about doing things right; leadership is about doing the right things’. He also said that ‘nothing is less productive than to make more efficient what should not be done at all’. While we couldn’t agree more that we must focus on the right things, Drucker wasn’t suggesting we slack off on the management side. We need to do both.
A necessary part of the management solution is the ‘theory of constraints’ (TOC), developed by the late physicist Dr Eli Goldratt. The whole point of this methodology is to bring focus to what you do. We must acknowledge that every system has a constraint. This constraint governs the rate at which value can be created. Therefore, any value gained by the constraint means value gained for the system as a whole. It sounds simple but has profound consequences for how you manage your organisation.
The innovations in productivity Ensemble brings beyond TOC come in how we combine it with the organisational design and development needed to implement the new thinking, as well as the technology that gives you the instrumentation and control to manage in real time.
What difference do you want to make?
According to Plato, Socrates used to say, ‘All I know for sure is that I know nothing.’ While that was a little bit disingenuous, a dash of humility goes a long way. By opening ourselves to the possibility that there are things we don’t know, we can challenge our current assumptions and see new ways out of the woods. Ultimately, we can shoot for the moon.
We invite you to explore these ideas with us. You might be at a different stage of your journey. And the journey itself may be fraught with uncertainty, but the Ensemble Way does offer a map and a compass to steer by. In fact, to go back to our original analogy, the technology we use is less a map and compass and more Google Maps and GPS.
We shouldn’t confuse the map with the terrain, though. What we offer is a methodology that uses systems thinking to identify how people, process and technology can work (and learn) together as an ensemble. While we don’t claim to have all the answers, our framework does let you clearly see your own organisation and its challenges, then make informed decisions about where best to focus your resources and energy. Contained in that is our promise that there are better ways to work that can inspire your team and uplift your vision.
Earlier, we said we define success by both your organisation’s goals and your own. Taking on these new ideas is not for the fainthearted. Even the most dynamic organisations have their own inertia when it comes to how they manage the work. (Often, objections to new ways are simply founded on the idea that ‘it’s just the way it’s done around here’.) But the rewards for those willing to take it on are huge. When we build our mastery doing the kind of work that really makes a difference, the day-to-day meaning of our jobs becomes transformed.
Of course, you should challenge the assumption that we can deliver on our promise. Some of what we say will be counterintuitive; other things will sound like so commonsensical you’ll wonder why so few people do them. (Then again, common sense isn’t always common practice.) We’ll develop these ideas over the coming articles. I hope you’ll come along with us on that journey.
Meanwhile, our website already includes a lot of information about our systems focus and organisation. Or if you’re ready to see the kind of difference we’re talking about, try our ‘Right Stuff’ workshop.
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* A few years ago, I realised I couldn’t name all the US states and my mental map was hazy at best. So I learned them all with an online test. (I couldn’t swear I’d pass the test now. Information has to be used, tested and recalled to become permanent. But that’s a different story.)
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Ensemble brings innovations in productivity to the planning and performance of work. Through consulting, technology and capability transfer, we help ambitious executives win remarkable results.
The healthcare professional: the hidden constraint in patient flow
Healthcare professionals are central to the patient’s progress from awareness of a therapy to successful long-term use. They identify risk, interpret evidence, diagnose conditions, discuss options, perform procedures, provide training and monitor outcomes.
Yet many medical device development programs treat healthcare professionals primarily as users to be trained or customers to be persuaded.
HCP-Centered Design takes a wider view. It examines the work healthcare professionals must perform, the system in which they perform it and the constraints that limit their ability to move suitable patients through the care pathway.
“If patient flow depends on a healthcare professional, that professional’s available capacity may determine how many patients ultimately receive the therapy.”
Healthcare professionals govern critical transitions
A medical device patient journey commonly depends on several healthcare professionals:
- A primary care professional recognizes a problem or makes a referral.
- A specialist assesses the patient and manages the disease pathway.
- Diagnostic professionals generate and interpret evidence.
- A managing physician supports authorization or reimbursement.
- An interventional specialist confirms eligibility and performs a procedure.
- Nurses, educators or allied health professionals help the patient adapt.
- Follow-up teams monitor efficacy and coordinate adjustments.
Each professional governs a transition in the flow of patients.
If one transition lacks sufficient capacity, information or clarity, the whole pathway slows. More marketing, sales activity or production capacity will not compensate for a shortage of specialist time or a burdensome diagnostic process.
This is why HCP-Centered Design is not simply about making an interface easier to use. It is about enabling the system of care to perform.
The HCP works within a system
A healthcare professional’s work depends on information and actions supplied by others. They may rely on referrals, patient histories, pathology, imaging, electronic records, clinical guidelines and the availability of equipment or trained colleagues.
After reaching a decision, they may need to explain it, document it, arrange authorization, coordinate treatment and prepare the next person in the pathway.
A technically strong solution can still create difficulty if it:
- Requires information that is hard to obtain
- Interrupts established clinical workflows
- Produces outputs that are difficult to interpret
- Adds documentation without removing other work
- Fails to connect with existing systems
- Demands training that cannot be sustained
- Transfers work or risk to another professional
- Provides a result without clarifying the next action
The relevant design question is not merely, “Can the HCP use this product?”
It is, “Does this solution improve the HCP’s ability to complete important clinical work within the conditions in which care is actually delivered?”
Identify the real healthcare professional personas
“HCP” is not one persona.
A general practitioner, specialist, interventional physician, nurse, technician and clinical administrator encounter different stages of the pathway. Each has different responsibilities, authority, expertise and exposure to risk.
Even within a profession, context matters. An experienced specialist in a major hospital may approach the same task differently from a professional who encounters the condition infrequently or works without immediate specialist support.
Useful HCP personas distinguish factors that influence work:
- Clinical responsibility and decision authority
- Frequency of encountering the condition
- Experience with the procedure or technology
- Access to information and specialist support
- Available time
- Confidence in interpreting results
- Responsibility for follow-up
- Exposure to clinical, legal or financial risk
These personas clarify who performs each job and what support each person requires.
Map the HCP journey
The HCP journey often begins before the visible clinical procedure.
It may include receiving a referral, gathering information, forming an initial view, ordering investigations, interpreting results, deciding whether the patient is eligible, discussing treatment, obtaining authorization, preparing for the procedure, delivering care and arranging follow-up.
At each stage, ask:
- What is the HCP trying to accomplish?
- What information is required?
- Where does the information come from?
- What decision must be made?
- What could cause delay or rework?
- Who depends on this action?
- What must happen before the patient can progress?
The resulting journey map should distinguish processing time from waiting time. A decision may require only minutes of specialist attention while patients wait weeks to access that attention.
This reveals the practical relationship between HCP capacity and patient flow.
Find the HCP constraint
The Theory of Constraints directs attention to the factor limiting the performance of the entire system.
In some pathways, the constraint may be the number of qualified interventional specialists. In others, it may be diagnostic capacity, physician confidence, authorization effort, operating room access or the time required to train patients.
The constraint may also be hidden inside the HCP’s working day.
A specialist supporting a therapy must still manage other clinical duties, administration, meetings, documentation and urgent cases. The question is not simply how many specialists exist. It is how much of their usable capacity is available for the activities upon which patient flow depends.
“The scarcest resource may not be the healthcare professional. It may be the few hours of focused capacity available for the critical work.”
Improvement away from this constraint can make performance worse. Sending more referrals to an already overloaded specialist increases the queue. Adding information may increase cognitive burden. Creating another approval may consume the capacity required to treat patients.
HCP-Centered Design seeks to protect and expand the capacity that governs flow.
Go to the clinical Gemba
Policies and procedures describe how clinical work should happen. Observation reveals how it actually happens.
Healthcare professionals routinely compensate for missing information, awkward interfaces and unreliable handovers. These workarounds may become so familiar that nobody reports them as problems.
Gemba research should examine:
- How the HCP prepares
- Which tools and information sources are used
- What interrupts the work
- Where the HCP waits or repeats activity
- How uncertainty is communicated
- What must be documented
- How work passes to the next person
- How the HCP recognizes that the job is complete
The purpose is not to judge the healthcare professional. It is to understand the system surrounding the work.
“A workaround is often evidence that the system has failed to support the person doing the work.”
Define the HCP’s job to be done
Healthcare professionals do not simply use devices. They use them to make progress in clinical work.
An HCP may need to identify risk, reach a confident diagnosis, select an intervention, perform a procedure safely, explain options, monitor progress or recognize deterioration.
A structured job map divides this work into eight stages:
- Define the intended clinical outcome.
- Locate the necessary information and resources.
- Prepare the patient, equipment and environment.
- Confirm readiness and choose between alternatives.
- Execute the clinical activity.
- Monitor its progress and results.
- Modify the approach when circumstances change.
- Conclude, document and prepare for subsequent care.
This wider view prevents the product team from concentrating exclusively on the procedure.
The greatest value may come from reducing preparation, improving decision confidence, clarifying an exception, simplifying documentation or improving the handover to follow-up care.
Convert experience into measurable outcomes
Comments such as “the interface is difficult” or “we need better information” indicate dissatisfaction, but do not provide sufficient direction for design.
They should be translated into measurable outcome statements, such as:
“Minimize the time required to identify which clinical information is missing before making a treatment decision.”
Or:
“Reduce the likelihood that a clinically significant change goes unrecognized between scheduled reviews.”
A broader population of healthcare professionals can then assess the importance of each outcome and their satisfaction with their current ability to achieve it.
Highly important and poorly satisfied outcomes provide a rational basis for prioritizing innovation.
“Adoption follows when a solution makes important clinical work safer, clearer or easier to complete.”
Apply FOCUS to HCP capacity
The five-step FOCUS process creates a practical improvement cycle.
Find the constraint. Determine which HCP activity or resource currently limits patient flow.
Optimise for it. Protect the constraint from avoidable work, missing information, interruptions and rework.
Collaborate around it. Align upstream and downstream teams so patients, information and resources arrive when required.
Uplift it. Add capacity, redesign responsibilities, improve technology or remove restrictive policies.
Start Again. Identify the new constraint once flow improves.
This approach allows the organization to distinguish activity from value. It also turns HCP engagement into an ongoing management discipline.
Connect HCP evidence with enterprise execution
HCP-Centered Design must connect clinical reality with patient needs, technology, regulation and business strategy.
A Value Management Office can help coordinate these perspectives across the product lifecycle. Its role is to ensure that projects, resources and stage-gate decisions remain connected to patient flow and business value.
The organization should be able to show:
- Which HCP groups influence the pathway
- What each group is trying to accomplish
- How the work happens in practice
- Which outcomes remain poorly served
- Where HCP capacity constrains patient flow
- How the proposed solution changes the wider care system
- How improvement will be measured
The goal is not simply a device that healthcare professionals can operate. It is a solution they can confidently incorporate into care and a delivery system capable of getting that solution to more patients.
What’s next?
Use the HCP-Centered Design assessment to determine how well your organization understands clinical work, HCP capacity and the constraints governing patient flow.
The resulting evidence should guide product design, process improvement and investment toward better products, delivered faster, with more lives changed for good.
Patient flow: the missing system in Patient Centered Design
Medical device companies devote enormous skill and investment to developing safe, effective products. Yet a technically successful device changes no lives while suitable patients remain unable to reach it.
Between a patient becoming aware of a therapy and receiving its intended benefit lies a pathway of referrals, consultations, diagnostics, approvals, procedures, training and follow-up. Every step consumes time. Between the steps, patients wait. At some points, they become confused, discouraged, ineligible or lost to the process.
Patient Centered Design must therefore address more than the design of the device. It must improve the performance of the entire system through which patients reach, receive and live successfully with the solution.
“A life-changing therapy changes no lives while patients remain trapped in the pathway leading to it.”
The patient journey is a flow system
A typical medical device journey may include:
- The patient becomes aware of a possible therapy.
- A primary care professional or specialist assesses the patient.
- Diagnostic work determines whether the therapy is appropriate.
- The patient secures authorization or reimbursement.
- An interventional specialist confirms and plans the procedure.
- The patient receives the device or therapy.
- The patient learns how to live with the solution.
- Follow-up identifies any necessary adjustments.
- Periodic reviews monitor longer-term efficacy.
Companies often manage these stages as separate functions. Marketing works on awareness. Medical affairs supports clinicians. Market access addresses reimbursement. Sales works with specialists. Clinical teams gather evidence. Training teams support adoption.
The patient, however, experiences one journey.
From the patient’s perspective, a delay between two organizational functions remains a delay. A repeated test remains repeated work. An unclear handover creates uncertainty regardless of which department owns it.
Patient Centered Design begins when the organization sees and manages this journey as a connected system.
Processing time tells only part of the story
Every step contains some necessary processing time. A consultation takes time. A diagnostic test takes time. An authorization must be assessed. A procedure must be performed.
The patient’s total lead time, however, also includes the waiting between these activities.
A consultation may take 30 minutes, but the patient could wait six weeks for it. A diagnostic test may take an hour, followed by another delay before a specialist reviews the result. Prior authorization may require little actual work while adding weeks to the pathway.
This distinction matters because organizations often improve processing time while leaving the larger queues untouched. Saving five minutes during an appointment produces little benefit if the patient waits months to reach it.
Patient Centered Design therefore asks:
- How long does each activity take?
- How long do patients wait between activities?
- How many suitable patients enter each stage?
- How many progress to the next stage?
- Where and why do patients leave the pathway?
- How much total time passes before the patient receives the solution?
The answers reveal the true performance of the patient system.
Find the constraint
Theory of Constraints teaches that the performance of any system is limited by a constraint. Improving a part of the system that is not constraining flow may create more activity without increasing results.
If diagnostic capacity is the constraint, generating more awareness may simply produce a longer queue for diagnosis. If specialist capacity is the constraint, accelerating authorization may move patients more quickly into another wait. If training after first use is inadequate, increasing procedures may produce poor experiences and avoidable follow-up demand.
“More activity at a non-constraint creates work in process. More capability at the constraint improves the system.”
The constraint is not always a physical resource. It may be a policy, an eligibility rule, missing evidence, a fragmented handover, an information delay or the cognitive burden placed on the patient.
The most important question is therefore not, “How do we improve every step?”
It is, “What currently limits the flow of suitable patients to successful use of the therapy?”
Understand why patients remain in or leave the flow
Numbers show where patients are lost. Patient research helps explain why.
Two patients with the same diagnosis may respond very differently. One may actively seek new treatment options. Another may delay action until symptoms become severe. A third may want help but lack confidence in navigating the healthcare system.
Meaningful patient segmentation considers characteristics that influence behavior:
- The importance the person gives their health
- Their confidence in dealing with healthcare professionals
- Whether they act independently or need encouragement
- Their comfort with technology
- The pressures of work, family and daily life
- Their ability to understand and act on clinical information
- Their willingness and ability to pay
- The outcomes they most want to achieve
These differences affect whether patients enter the pathway, remain engaged and successfully adopt the solution.
Go to the patient’s Gemba
The Gemba is the place where work actually happens. For patients, this includes the home, clinic, hospital and all the places where they manage their condition between formal encounters.
Interviews alone may miss important evidence. People normalize inconvenience, forget workarounds and simplify their past decisions. Observation allows the development team to see what patients actually do.
Good research combines three activities.
Observe. Watch how patients obtain information, prepare, use the solution and respond when something goes wrong.
Immerse. Understand the physical, emotional and practical conditions surrounding the experience.
Engage. Ask open questions that allow patients to describe their goals, fears and frustrations in their own language.
The purpose is to discover the patient’s reality before asking them to evaluate the organization’s preferred answer.
Understand the patient’s job to be done
Patients rarely want a medical device for its own sake. They want the progress it may enable.
They may want to recognize deterioration earlier, preserve independence, reduce pain, avoid repeated visits, return to work or prevent a disease from controlling daily life.
A useful job map examines eight recurring stages:
- Define what must be achieved.
- Locate the required information and resources.
- Prepare for the activity.
- Confirm readiness and choose between alternatives.
- Execute the activity.
- Monitor whether it is working.
- Modify the approach when circumstances change.
- Conclude or prepare for what follows.
This reveals opportunities beyond the immediate use of the device. The most valuable improvement may involve helping patients prepare, confirm readiness, recognize an exception or understand what happens next.
Turn patient experiences into evidence
Stories create understanding, but investment decisions require structured evidence.
Patient observations and comments should be converted into outcome statements that identify:
- The desired direction of improvement
- A measure of success
- The object being controlled
- The circumstances in which it matters
For example:
“Minimize the time required to recognize that my condition has changed sufficiently to require clinical help.”
Patients can then assess the importance of each outcome and their satisfaction with their current ability to achieve it.
Highly important and poorly satisfied outcomes represent genuine opportunities. This prevents teams from prioritizing attractive features that do not materially improve the patient’s life or progress through the pathway.
“Innovation becomes valuable when it improves an outcome that matters and remains poorly served.”
Apply the five-step FOCUS process
The Patient Centered Design pathway can be improved through a repeating discipline:
Find the constraint. Identify what currently limits patient flow or successful use.
Optimise for it. Make the best possible use of existing constraint capacity.
Collaborate around it. Align functions and partners so their actions support the constraint.
Uplift it. Add capability, remove restrictive policies or redesign the pathway.
Start Again. Once the constraint moves, identify and address the next limiting factor.
This prevents improvement from becoming a collection of disconnected initiatives. It directs scarce resources toward the factor that most strongly governs the result.
Patient Centered Design is an operating system
Patient insight should influence more than early product design. It should shape clinical evidence, regulatory strategy, reimbursement, manufacturing, education, market development and post-market support.
The organization should be able to show:
- Which patients it intends to serve
- What those patients are trying to accomplish
- How the complete patient pathway operates
- Where patients wait or leave the flow
- Which outcomes remain poorly served
- What currently constrains successful patient access
- How the proposed solution improves the whole system
The goal is not simply to place the patient at the center of a diagram. It is to organize the enterprise around delivering better products faster, so that more lives can be changed for good.
What’s next?
Use the Patient Centered Design assessment to determine how well your organization understands its patient journeys, priority outcomes and constraints to patient flow.
The result should be more than another collection of patient opinions. It should provide evidence that directs strategy, investment and execution toward the changes that matter most.
More than just work
Discover better ways to do better work.
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We alternate our own actionable articles with three relevant links from other authorities.
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More than just work
Discover better ways to do better work.
Fresh insights, every Friday
We alternate our own actionable articles with three relevant links from other authorities.
We’ll only use your email address for this newsletter. No sales calls
