Culture is, pretty much, a force behind everything we do as human beings. Indeed culture is to humans as water is to fish. Asking them ‘What is water?’ would seem a futile question. It is simply, and in a profound way, the medium in which they live their lives.
To we humans, culture is both the light we project and the lens by which we see it. Sir Edward B Tylor, considered by many as the founder of cultural anthropology, said culture is ‘that complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of society’.
These attributes define us as human beings, taking us beyond mere material existence—common to all in the animal kingdom—and offering us a means of interpreting the world around us, interacting with it and creating change.
My purpose here, though, is not to look at culture from such a broad perspective. I want to narrow down the inquiry to explore what it is about the cultural domain that we need to take account of in any exploration of people at work.
Several years ago, I led an intervention on a troubled construction site that was run as a joint venture between a Tier-One Australian contractor and a European multinational. The head of the new venture needed to know when first production was going to happen. It would have a direct bearing on the total cost of the project, the timing of revenue generation and any damages they would have to pay to the owner if expectations weren’t met. My firm was asked to help define the project’s critical path.
A particularly difficult part of the construction phase involved choreographing the various trades—civil, mechanical and electrical—to minimise downtime and rework. Computer modelling had already provided a three-dimensional representation of the material components of the area. We added the time dimension to the model so everyone involved could visualise what was being planned, identify any clashes and make suggestions for improvements.
Furthermore, it was possible to integrate the computer-modelling program with the project’s procurement system. Then, through some clever colour coding, we could identify what was already on site, what was on the way and what needed expediting. For the younger generation, who grew up doing their engineering on computers, it was the realisation of a vision, where the project could be built twice—once on a computer, the second time for real.
For the project director, however, who had worked on many of Australia’s iconic engineering projects, it was a nightmare. The man was coming to the end of his career and couldn’t get his head around the idea that his command and control came from opening his laptop, clicking the mouse and striking a few keys. This man’s experience was built on forty years of unfurling printed drawings in construction huts, getting dirt on his boots and directing traffic around the site. To him, work meant a load of rebar steel arriving and him being on site to instruct a foreman to get one of his people to unload the bundles, group them by construction zone, and start the process of tying them into cages. The new system meant the cages would arrive pre-assembled and bar-coded for scanning and positioning to the relevant part of the site.
The project director wasn’t the only person having difficulty with the new system—a genuine generational divide saw splits among the professional engineers all the way through to the foreman and tradies. Some were perfectly comfortable with computers and loved the idea of the virtualisation of work; others hated it for taking away their physical control of the world around them.
Storytelling is necessary, but not sufficient
Part of my process was to work with a colleague from the venture introducing the new technology in as seamless and effective a way as possible. She was a smart engineer with a doctorate in the adoption of innovation in the construction industry. One of her tasks was to turn an existing publication about the company history into an e-book so it might reach a much wider audience, especially for staff to appreciate the deep roots of their culture. Fortunately, she’d found some remarkable stories in the book about the company’s early days.
One story told of the owners of the business—at that time a private company in family hands—deciding to buy an aeroplane. The plane wasn’t bought because they felt that they’d ‘made it’ and could now afford the high life. Rather, it would expedite their processes and help bring their projects in on time and on budget. These men (and they were all men—another sign of those times) had to be on the ground at geographically dispersed sites to identify and resolve the most pressing problems. Since time was key, the means to travel quickly from site to site was crucial. Here, technology was solving a problem of time and space.
Another story involved the teams scheduling their work phone calls for the unusual time of 5am—not because they had a particular desire to extend their working days. But in the 1960s, many places in Australia were still only served with party lines; if you didn’t get in early, you took the risk of not getting your call. In a world of telegrams, a dawn phone call was a technological competitive advantage.
Similarly, whenever their supplier, Caterpillar, came up with a new bulldozer capable of moving more dirt more quickly, this company was first in the queue to buy it. Everyone, from management to workers, could see the productivity gains, even if there was an upfront investment.
Finally, my colleague found a heart-warming story of the pregnant wife of one of the senior managers crossing a flooding river to carry dynamite in her ‘ute’ to the site where it was needed. She did this with little regard for her own health and safety. This bold woman was imbued with the spirit of doing whatever it took to build the Australia of the future. On time, and on budget!
We felt each of these anecdotes could help us in our quest to shift perspective of the digiphobes and bring them into this brave new world. Each, we figured, could act as anchors into the past, allowing us to show that the adoption of the latest technology—in this case the computer technology we were advocating—fitted well with the organisation’s ‘can do’ culture.
We were sure it mattered to our naysayers, that this culture had helped the company grow from a small family business to a listed corporation, doing work in Australia and all across Asia and the Middle East.
However, romantic stories of derring-do didn’t cut it. And it seemed to matter little that their stated company values—emblazoned on their masthead—were trust, innovation, passion and excellence. It simply wasn’t enough to tell them about clear productivity improvements, nor how these made them more competitive. This led me into a deeper investigation of the anxiety behind people’s resistance to change.
Overcoming our learning anxiety
If ever there is to be an increase in momentum towards a concept of better ways of working, people within organisations need to increase their capacity to learn. It turns out that building a culture of learning within organisations is one of the best ways of reducing the anxiety associated with change. But achieving such a culture is no easy task.
Ed Schein, Professor Emeritus at the Sloan School of Management at MIT, talks of the natural anxiety associated with any learning. In order to lessen that anxiety, we have to accept our own limitations and deal with the consequence that we might fail to achieve a requisite level of competence, or simply make a fool of ourselves. We know, logically, it’s not possible to learn anything without making mistakes; if we could do the thing already, we’d have nothing to learn.
Schein maintains that playing against this ‘anxiety of learning’ is an ‘anxiety of survival’. Learning only really occurs, he suggests, when the anxiety of survival is higher than the anxiety of learning. So, for example, if your boss tells you you’ll be fired unless you figure out how to properly use the new performance management system, you’ll probably learn how to use it; anxiety around surviving in the job trumps the anxiety about how to use the new performance management system. Put a little more humorously, when I asked one participant of a workshop I was running why he was attending the session, he replied, ‘What interests my boss, fascinates me!’
In the case of our previously mentioned project director, clearly there was anxiety that the youngsters, brought up in a digital world, would mock him for being so ineffective—or even incompetent—with the new technology. They had already laughed at the fact that he got his secretary to print out his emails, and that he crafted his grammatically perfect responses with a fountain pen in well-polished cursive writing.
But his resistance to the new technology was no laughing matter. He could not avoid the change. The company simply had to exploit the innovation in productivity that the computer modelling enabled. To use an analogy he would have readily accepted—rejecting the innovation would be like insisting on retaining the pick and shovel even after the bulldozer had been invented.
The commercial imperative of survival sat on the other side of the learning anxiety scale. If he was not open to a profound transformation through the adoption of the new technology, either he or the firm would go the way of the dinosaur. And although it took a couple of years, he escaped into retirement as the company was swallowed in a giant merger, stripped of its ability to master its own destiny.
A more humane (and therefore more effective) alternative to ratcheting up the anxiety of survival to force learning within an organisation is to decrease the anxiety of learning. That is, to create the conditions in which learning is fun, attractive and a rewarding source of personal, team and business growth.
Many approaches can foster such an environment, but perhaps the most important is to build a culture that understands the maxim ‘fail often to succeed sooner’ and which encourages people to confess their ignorance without shame.
In later posts, we’ll explore more how culture—and the language we use to make meaning—affects your organisation’s ability to successfully enter future after future.
Ensemble brings innovations in productivity to the planning and performance of work in a changing world. Let’s redefine what’s possible.
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
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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
