What an age we live in. I don’t have to go to the library to avail myself of the world’s best thinkers—I need only tune in to YouTube. I still love to read, but how very convenient to be able to watch or listen to some of the world’s greatest thinkers on my way to and from work, whether in the car ride into the office or on a flight across the continent.
While some complain about the algorithms that select what you see based on your past preferences, I’m still in the phase of amazement that it has served me up such rich pickings, the likes of which I would never have known about unless I was an academic, used to cross-referencing citations.
[Listen to audio version, read by David Hodes]
The major theme of all my listening has been around the foundational idea of our Western civilisation—the idea of freedom of speech. This year a group of proponents of free speech was named the Intellectual Dark Web by one of their members, Eric Weinstein, a noted mathematician and managing director of Thiel Capital. The group gained some notoriety after the moniker was picked up in a May 2018 New York Times article. In truth, the group is loosely affiliated but they often end up interviewing each other or sharing stages. The core includes, in alphabetical order, Ayaan Hirsi Ali, Sam Harris, Heather Heying, Claire Lehmann, Douglas Murray, Maajid Nawaz, Jordan Peterson, Joe Rogan, Dave Rubin, Ben Shapiro, Michael Shermer, Debra Soh, Christina Hoff Sommers, Bret Weinstein and Eric Weinstein.
In their different ways, these defenders of free speech have reawakened in me its centrality to freedom itself and its importance to me. As I listened, I found myself thinking increasingly about the implications of their words for the world of business. For we who work in, manage, lead or own businesses are an integral part of the civilisation in which we conduct those activities. Our business lives are not separate from the culture in which that business is done. Instead, our actions shape the culture and, in turn, are shaped by it. We ignore our hard-won freedom of speech at our peril.
“Our business lives are not separate from
the culture in which that business is done.”
The basic tenet of freedom of speech is that we cannot advance our knowledge of our world and how to be productive actors in it if we are not allowed to engage in free speech, and its associated virtue of freedom of thought. I recall the debate in Australia around the failed attempted to repeal section 18c of the Racial Discrimination Act, which reads, in part, that it is an offence to ‘offend, insult, humiliate or intimidate another person or a group of people’. This seemed perfectly reasonable until a series of cases made me aware of the idea that it is impossible for me to be the custodian of someone else’s offence. There is much law against defamation, incitement and the like, so why was it necessary and how was it possible to protect the feelings of others for words which I say?
Then came the storm of Jordan Peterson in a famous interview with Cathy Newman, during which he made the case for refusing to be compelled to use speech under Canada’s Bill C16, ostensibly designed to show compassion for transgender people by making it an offence not to call them by the gendered pronoun of their choice. I was hooked by this professor of psychology who has spent his life trying to understand the root causes, within the human mind, of the rise of the heinously murderous totalitarian Nazi and Communist regimes of the 20th Century.
One of the easiest ways to explore the opinions of the thinkers listed above is to visit the Rubin Report on YouTube. Dave Rubin is a political commentator who has an endearing way of drawing out his guests reminiscent of Larry King (seeing his interview with King is a great reminder of the roots of this form of communication). I particularly enjoyed watching Rubin interview Thomas Sowell, Larry Elder and Candace Owens as they smashed up against my own preconceptions of the range of what black Americans think and what these free individuals have to say about the perception of—and causes and remedies for—what ails our societies.
You could also follow great women thinkers, like Christina Hoff Somers, and our own Australian stars, Claire Lehman and Bettina Arendt. Or hear Douglas Murray sharing with Joe Rogan a very confronting view set out in his book The Strange Death of Europe, or Jonathan Haidt on the wiring of the righteous mind. These are all long-form interviews or talks, of which there are many more. They are a complete contrast to the soundbites of the mainstream media and may be as revolutionary to the spread of free thought as the printing press.
So, what does all this have to do with business? Allow me to give two examples from my consulting activities last year.
One client, with whom I have had several assignments stretching back 18 months, had applied my services in their engineering division and, after some success there, I was invited to facilitate a dialogue amongst the senior leadership of the local entity of this global Australian brand. Nine months in I was convinced the business was going from bad to worse and felt that their compass was pointing in the wrong direction. I wrestled with my conscience about whether to stay silent on the matter and do what was expedient to secure further work, or to speak my truth to power and let that truth create the world I seek to inhabit. The employees had already suffered much by way of overwork and underinvestment in their processes, systems and personal development.
“I was convinced the business was going from bad to worse and
felt that their compass was pointing in the wrong direction.”
After much deliberation, and reflecting on my core belief that people have the right to be well managed, I turned to the principles I wrote about in my book More Than Just Work. At the heart of all of my principles is the Golden Rule: ‘do unto others as you would have them do unto you’. In a much shorter than planned meeting with the Group CEO, I was immediately asked to leave, had the full force of their legal powers on my case, was banned from talking to any of their employees other than those designated to review my findings and finally received a letter saying that after their investigation there was no substance to what I had to say and, if ever there was, they already knew about it and had it under control.
I retraced every word I’d said and asked some trusted friends to test the validity of the assertions I was making. I had been consciously respectful and acted from a place of integrity, wanting only what I thought was best for their business. Getting divorced from a long-term client like that with no notice was initially a huge shock to the system. I can still vividly recall my counterpart in the company walking past me as I waited for my Uber on the pavement, too dumbstruck to say anything, looking back at me over his shoulder with a mixture of pity and disdain. In an instant, I’d become a pariah. And yet, I felt an enormous sense of relief at the same time. I couldn’t hold the lie in any longer. Whatever the consequence, I had to speak my truth.
Despite feeling deeply shaken by the instantaneous and brutal reaction to what I had to say, I also felt liberated from the tyranny represented by the organisation and its most senior management. It felt amusingly ironic to me that this company had been a vocal champion of the recent plebiscite on gay marriage and plastered its diversity credentials wherever it could attract an eye or an ear. Yet diversity of that sort apparently didn’t lead naturally to accepting diversity of viewpoints when it came to the leadership and management of operations.
I cannot complain that my own rights were trampled upon; companies are not democracies, and the executive team, appointed by the board, on behalf of the shareholders, is entitled to do as it wishes within the law. But, how very sterile they become when they so instantly dispose of a messenger carrying a message they don’t want to hear. How brittle and feeble become their responses to the world changing around them? What a price they pay for such censorship of speech. How delinquent are they in the impoverishment of their leaders and their corporate capacity for true leadership?
I have been around long enough and suffered sufficiently the slings and arrows of outrageous fortune to know that fate can often be your friend. As I stepped into that Uber I got a call from another client. After a preliminary assignment they had decided to continue with a substantive piece of work. The Dalai Lama has an expression: ‘sometimes be grateful for what you don’t get’. My liberation from the one assignment meant I could put all my energy into making a remarkable success of doing meaningful work with people in the same dance as me.
This company also had a diversity agenda, which in truth meant they wanted more women in the workplace and in the executive suite. One of their rivals had stated that they would be 50:50 men and women by 2025, and so, not to be outdone, the corporates in head office said they would get there by 2023. The trouble was that the business is in heavy industry and not much had been automated. Heavy equipment needs brute strength to operate and those women who were involved in the field were getting injured at a higher rate than the men. It also meant that the men were becoming resentful of having to carry more of the load to compensate.
A senior woman manager talked to me about the folly of the idea of having a 50:50 workforce. She told me this would mean a freeze on hiring men for at least the next five years. And, even if they were to abide by such a policy, where on earth would they get these women from? Study after study has shown that, on balance, men prefer things and women prefer people. In the Scandinavian countries, the most gender egalitarian on earth, the result has been to see a widening of the preferences made by men and women—more male engineers and more female doctors and nurses. No one, she stated, should mistake her passion for equality of opportunity. In our age, no one—regardless of sex, race, ethnicity or religion—should be denied the opportunity to follow their will. But, there is no sensible way to manage an equality of outcome without descending into tyranny. How refreshing to hear such talk from a woman without the anesthetising effect of an ideological argument.
We need more free speech in business, not less. We have a very precious heritage in our Judeo-Christian civilisation that is built on the proposition that each of us is created in the image of God and we are therefore, each and every one of us, equal before all. As a consequence, we are free to think as we will, and that is not something we should ever surrender without a fight.
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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:
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[Background photo by Naveen Chandra on Unsplash]
“If liberty means anything at all, it means the right
to tell people what they do not want to hear.”—George Orwell
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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.”
A medical device patient journey commonly depends on several healthcare professionals:
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.
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:
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?”
“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:
These personas clarify who performs each job and what support each person requires.
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:
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.
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.
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:
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.”
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:
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.
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.”
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.
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:
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.
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.
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.”
A typical medical device journey may include:
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.
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:
The answers reveal the true performance of the patient system.
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?”
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:
These differences affect whether patients enter the pathway, remain engaged and successfully adopt the solution.
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.
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:
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.
Stories create understanding, but investment decisions require structured evidence.
Patient observations and comments should be converted into outcome statements that identify:
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.”
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 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:
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.
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.
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