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Springboard: Mindset

David Hodes, Founder

The latest in our series that uses the ‘book review’ format as a springboard into a wider conversation about the world of work—and how to do it better.

Mindset by Dr Carol S Dweck

____________________________

Which mindset do you have? Read each statement and decide if you mostly agree with it or disagree with it:

1. Your intelligence is something very basic about you that you can’t change very much
2. You can learn new things, but you can’t really change how intelligent you are
3. No matter how much intelligence you have, you can always change it quite a bit
4. You can always substantially change how intelligent you are

If you mostly agree with statements 1 and 2, you may have a ‘fixed mindset’. If you agreed with statements 3 and 4, you likely have a ‘growth mindset’. So what’s the difference? And why does it matter?

This test comes early in Mindset, first published in 2006 by Carol Dweck, a psychology professor at Stanford University. In Dweck’s words ‘the fixed mindset makes you concerned with how you’ll be judged, the growth mindset makes you concerned with improving’.

In a fixed mindset, students believe their basic abilities, their intelligence, their talents, are just fixed traits. They have a certain amount and that’s that, and then their goal becomes to look smart all the time and never look dumb. In a growth mindset, students understand that their talents and abilities can be developed through effort, good teaching and persistence. They don’t necessarily think everyone’s the same or anyone can be Einstein, but they believe everyone can get smarter if they work at it.

When I first encountered those initial four statements, I really had to challenge my own baked-in ideas of where achievement comes from. I found myself going back to my school and university days and thought about what I did when the going got tough. I knew I was good at verbal and numerical reasoning, but not so much in 2D representations of 3D problems. Likewise, when I was learning guitar, flute and piano, if ever I got to something really hard, I would tell myself that I wasn’t really any good as a musician and would abandon the pursuit of musical excellence in favour of what I felt were my core strengths.

At the heart of Dweck’s ideas is the perennial question about nature versus nurture. How much of what we achieve is due to our natural abilities and what is gained from the hard work of learning? The idea of always being able to do better by adopting a growth mindset has tremendous appeal. But could I ever be Usain Bolt? Surely there is a limit to accomplishment in any given field based on the effort applied to natural endowment.

It’s heartening when Dweck references the story of the kids from Chicago who, having exhausted every other possibility, learned under Marva Collins to engage with Chaucer and Shakespeare—in Year 4! (Watch an extract from the original 60 Minutes episode.) Does it really matter, then, that we may not be another Mozart or Darwin, when we are all capable of so much more if we embrace the growth mindset over the fixed?

A theme repeated time and again in Dweck’s book is the idea that when one praises someone, that praise should always be directed at the effort applied and not to the outcome. Indeed, she makes the point that much as we might want to bolster the confidence of our children, or the teams we lead by lauding their natural abilities, such an approach is poison for the growth mindset.

To be sure, Dweck makes the point that effort alone is not going to deliver a growth mindset:

The growth mindset was intended to help close achievement gaps, not hide them. It is about telling the truth about a student’s current achievement and then, together, doing something about it, helping him or her become smarter.

Time and again Dweck talks about the development of learning strategies by both students and teachers. We all have different ways of learning, of apprehending the world around us and integrating new ideas and concepts with our existing models.

Mindsets and intelligences

I’m a fan of Howard Gardener’s work on different intelligences, and Dweck’s experience of adopting individual strategies for individual learners makes sense when you consider that we all have different mixes of what Gardner defines as follows:

Visual-Spatial – think in terms of physical space, as do architects and sailors. Very aware of their environments. They like to draw, do jigsaw puzzles, read maps, daydream. They can be taught through drawings, verbal and physical imagery. Tools include models, graphics, charts, photographs, drawings, 3-D modeling, video, videoconferencing, television, multimedia, texts with pictures/charts/graphs.

Bodily-kinesthetic – use the body effectively, like a dancer or a surgeon. Keen sense of body awareness. They like movement, making things, touching. They communicate well through body language and be taught through physical activity, hands-on learning, acting out, role-playing. Tools include equipment and real objects.

Musical – show sensitivity to rhythm and sound. They love music, but they are also sensitive to sounds in their environments. They may study better with music in the background. They can be taught by turning lessons into lyrics, speaking rhythmically, tapping out time. Tools include musical instruments, music, radio, stereo, CD-ROM, multimedia.

Interpersonal – understanding, interacting with others. These students learn through interaction. They have many friends, empathy for others, street smarts. They can be taught through group activities, seminars, dialogues. Tools include the telephone, audio conferencing, time and attention from the instructor, video conferencing, writing, computer conferencing, E-mail.

Intrapersonal – understanding one’s own interests, goals. These learners tend to shy away from others. They’re in tune with their inner feelings; they have wisdom, intuition and motivation, as well as a strong will, confidence and opinions. They can be taught through independent study and introspection. Tools include books, creative materials, diaries, privacy and time. They are the most independent of the learners.

Linguistic – using words effectively. These learners have highly developed auditory skills and often think in words. They like reading, playing word games, making up poetry or stories. They can be taught by encouraging them to say and see words, read books together. Tools include computers, games, multimedia, books, tape recorders, and lecture.

Logical-mathematical – reasoning, calculating. Think conceptually, abstractly and are able to see and explore patterns and relationships. They like to experiment, solve puzzles, ask cosmic questions. They can be taught through logic games, investigations, mysteries. They need to learn and form concepts before they can deal with details.

Gardner says that these differences ‘challenge an educational system that assumes that everyone can learn the same materials in the same way and that a uniform, universal measure suffices to test student learning. Indeed, as currently constituted, our educational system is heavily biased toward linguistic modes of instruction and assessment and, to a somewhat lesser degree, toward logical-quantitative modes as well’. He argues that ‘a contrasting set of assumptions is more likely to be educationally effective. Students learn in ways that are identifiably distinctive. The broad spectrum of students—and perhaps the society as a whole—would be better served if disciplines could be presented in a number of ways and learning could be assessed through a variety of means.’

Gardner first proposed these ideas to the general reader in Frames of Mind: The Theory of Multiple Intelligences, in 1983, and his good ideas were seized on by high-school teachers who used them (and other sources) as the basis of the ‘learning styles’ approach. This has been debunked as having little relevance to positive outcomes. Other factors—such as student interest and backgrounds and learning disabilities—correlate more strongly with success than learning styles [see infographic]. In this Washington Post piece, however, Gardner makes it clear that multiple intelligences and learning styles are not the same.

Does it really matter, then, that we may not be another Mozart or Darwin, when we are all capable of so much more if we embrace the growth mindset over the fixed?

Whilst the emphasis of Gardner is on school and university students, I wonder what the implications are for those trying to create a competitive advantage in their businesses through the development of learning organisations? In fact, I am not a fan of the idea that organisations learn—people within organisations learn, and it is up to the leaders within the organisation to foster the conditions most favoured to accelerating learning. What Dweck articulates in Mindset provides us with the confidence to make the assumption that we can all substantially improve our learning and thus contribute to both our own and our organisations’ growth.

In her book, Dweck covers a wide range of areas where these fundamental ideas of fixed and growth mindsets can be applied: in schools, sports, the arts, relationships and business. In the latter, she contrasts the fixed-mindset styles of Chrysler’s Lee Iacocca, Enron’s overreaching executives and a few other failed CEOs with the growth-mindset approach of GE’s Jack Welch, IBM’s Lou Gerstner and Xerox’s Anne Mulcahy to compelling effect.

Dweck uses powerful storytelling to contrast the difference between those with a fixed mindset and those with the growth. The essence of her idea is that we are all able to do better at anything we turn our minds to if we learn to love the challenge of learning. What struck me most was that not only are we all capable of adopting the growth mindset, but that access to this ultimately more fulfilling way of approaching life’s challenges is available to all people of all ages. Along with this idea is the notion that each of us is also capable of surrendering to the fixed mindset at any moment.

Like all good ideas, Dweck’s work took a while to make it into the mainstream and, as with Gardner’s ‘intelligences’, the application of mindsets as a panacea for a wide range of educational ills has attracted a few critics. But the core idea seems unassailably true and resonates strongly with me. In my domain of organisational excellence, the big question is: What might it take for senior executives to invest the time and money into shaping each individual’s learning so they can do the equivalent of those Chicago fourth-graders getting comfortable with Chaucer and Shakespeare?

You can test your own mindset on Dweck’s website. Bear in mind that you may have a fixed mindset in one area of your life and a growth mindset in another. And remember, too: you can always fix a fixed mindset—with potentially remarkable results.

____________________________

What’s next?

The change from standard thinking to Theory of Constraints (TOC) is both profound and exhilarating. To make it both fun and memorable, we use a business simulation we call The Right Stuff Workshop.

We’d love to run it with you. To learn more:

  • download the brochure (no email required)
  • schedule a call

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    [Background photo by Derril Roy on Unsplash]

    ‘In the long run, the only sustainable source of
    competitive edge is your organisation’s ability to
    learn faster than its competitors’—Peter Senge

    ____________________________

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The healthcare professional: the hidden constraint in patient flow

Ensemble Administrator

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:

  1. Define the intended clinical outcome.
  2. Locate the necessary information and resources.
  3. Prepare the patient, equipment and environment.
  4. Confirm readiness and choose between alternatives.
  5. Execute the clinical activity.
  6. Monitor its progress and results.
  7. Modify the approach when circumstances change.
  8. 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.

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Patient flow: the missing system in Patient Centered Design

Ensemble Administrator

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:

  1. The patient becomes aware of a possible therapy.
  2. A primary care professional or specialist assesses the patient.
  3. Diagnostic work determines whether the therapy is appropriate.
  4. The patient secures authorization or reimbursement.
  5. An interventional specialist confirms and plans the procedure.
  6. The patient receives the device or therapy.
  7. The patient learns how to live with the solution.
  8. Follow-up identifies any necessary adjustments.
  9. 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:

  1. Define what must be achieved.
  2. Locate the required information and resources.
  3. Prepare for the activity.
  4. Confirm readiness and choose between alternatives.
  5. Execute the activity.
  6. Monitor whether it is working.
  7. Modify the approach when circumstances change.
  8. 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.

READ MORE

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