STAY CONNECTED AND SIGNUP TO RECEIVE INSIGHT updates
Our evolution has been a constant struggle to find the balance between the chaos of primordial nature and the order of cultural development. As a species, our primal wiring is to fear the unknown. But nothing remains the same, and all things must pass.
[Listen to audio version, read by David Hodes]
The natural state of our minds, when exploring the frontier of our experience, is to struggle with the flight, fight or freeze impulse. To be most fully alive, however, we must find the courage to explore beyond our walled garden of safety. Besides the obligation to confront or avoid threat, the work is to identify opportunity and bring to ourselves and our communities a steady stream of innovation and novelty.
Those discoveries beyond the frontier of the known need to be understood, codified and incorporated into our existing stores of knowledge in a way that ensures a certain dynamic tension between the explored and the unexplored. A failure to venture beyond the frontier inevitably produces sterility and tyranny—old rules used by decree to bend new reality to its will. Conversely, if there is no order, there is no foundation upon which the new insights can be built, leading to atomisation and anarchy.
It turns out that our brains are built to accommodate and integrate these two domains of life—the chaos and the order. Our right brain is a patternseeker and sensemaker. When we act, its operation looks into unexplored territory and seeks to discern whether the phenomena it finds represent threat or opportunity. If opportunity, it undertakes the process of sense- and meaning-making. The left hemisphere of the brain is the repository of order, the explored territory, the place where wisdom, cultural norms and security abide. Grounded in the deeds of the heroes of the past, the left brain represents the solid foundation upon which we shape into value the new thinking of the right brain.
As an aid to understanding the fundamental concepts of chaos and order as they relate to your organisation, at Ensemble, we have developed the ‘dynamo’ model. When you look at the categories listed in the diagram, think of yourself as being right in the middle of it.

A dynamo generates energy and is where we want to be to work, and live, to our fullest potential. When you combine a grand vision with remarkable operating discipline, the creative tension between the two provides the best possible chance of outperforming even your own expectations. In our model, the vision axis stands for the ‘chaos’ outlined above and the ‘operating discipline’ for the order.
Let’s take a look at each of the eight categories in a little more detail.
Deadbeat: A person who turns up without any idea of what their goal is, how their future might unfold, and what agency they have in getting there is the deadbeat. They are ill-disciplined, indifferent to process and likely complain incessantly that the world will not bend to make them happy. They are a drag on team morale and a drain on energy. Any initiative is met with a cynical sneer and their level of motivation to get any work done is very low. They have no sense of how what they do will carry them forward, as they have nowhere to which they’re moving.
Drifter: The drifter has an idea of what a brighter future could hold, but they have not put in the hard work of fully developing their vision. They are comfortable following a general direction, but readily give up when the going gets tough. It’s easy come for them and then just as easy go. They’re the sort who will tell you that they’re ‘ideas’-type people and are only interested or good at the ‘big picture’. Whenever there is an assignment to hand out, they’re usually at the back of the queue, hopeful that they can hitch a ride off of their more conscientious colleagues. They are quick to claim credit for any successes and have an oversized sense of the value of their ideas.
Dreamer: These impassioned souls have a powerful sense of calling to their vision but spend an inordinate amount of time inhabiting the future, which is yet to be built. Their theme is a constant ‘wouldn’t it be good if…’, but it rarely gets beyond that. When paired with a ‘doer’, they can provide a burst of energy, but it soon becomes apparent that their head is in the clouds and they become a distraction. They are highly idealistic and very low on pragmatism. They build dream upon dream without ever seeing a result and are eventually written off by their colleagues as being nice, with some good ideas, but useless.
Devotee: Moving beyond the mere words of the dreamer, devotees have a strong desire to turn their vision into reality. They have organising skills and can mobilise a team to pursue an audacious goal. They have difficulty, though, with follow through. The processes they follow are rarely standardised and they thus spend too much time reinventing the wheel every time a new initiative is launched. They are fully committed to being open about innovative thinking, but struggle when wrestling with the devil in the detail. They often need to be goaded into action as they indulge their tendency to get lost in reverie. But, once they have the bit between their teeth, they head off at an inspiring gallop until they run out of puff. They consume too much energy running an always hands-on show rather than investing the time to set up the system to do the heavy lifting.
Definer: With a strong background in process management, definers do things by rote. These types are more interested in being ever better in their career discipline and forget why they are there in the first place. They may have qualifications after their name which indicate levels of achievement in the field of projects, production, and process management and will routinely complain that, but for the ill-discipline of the people they are managing, all would be well in the world. ‘Definers’ are seen by the people they micromanage as very two-dimensional. As a result, those being managed find it challenging to feel inspired about their work.
Decreer: The tyrant in the pack. These types have a lot of power, and everything about them is about getting others to do their work the way it is decreed. There are deficient levels of trust, and the team usually only stays on because they either have no other options or haven’t yet sorted them out. There are frequent requests from team members to managers further up the chain to transfer them to other projects or business units resulting in high levels of team churn. While the operating procedures are well documented, and process mastery is a given, the decreer often uses the systems as a big stick with which to beat the team into compliance. The objective is conformance rather than performance.
Deliverer: Strong on operating discipline, deliverers have one eye fixed firmly on the vision for the future. They make for loyal followers, but find it difficult to provide their less-disciplined colleagues with a compelling case for why a high level of discipline is essential for realising the vision. They are often anxious about their role as hero and would rather play second fiddle. They find comfort in process and analysis, but prefer to use their mastery of data to support the effort rather than lead it. There is a threshold of leadership they will not cross as they believe deep within that they are incapable of mustering the courage to lead something genuinely new. They are by nature incrementalists, preferring to serve the vision of their leaders rather than imagine themselves capable of heroic deeds.
Dynamo: A source of energy for everyone. Dynamos are a force of nature whose courage is in direct proportion to their grand vision. They have a clear idea of where they want to go and have a highly disciplined mind when it comes to working out how to get there. They can handle competing social, economic and environmental demands in a way which is held together by an incandescent will to achieve what would otherwise be thought unreasonable or impossible. Their teams enthusiastically embrace their big idea and are inspired to turn up as the best version of themselves. Those teams deeply appreciate that their dynamo leader always has in mind that what they do is in service of the greatest good for all.
Dynamos have an incredible attention to detail and great mastery in the disciplines of the planning and performance of work. They are inveterate learners and would rather be proven wrong than right. They never sacrifice the multifaceted achievements of doing profoundly meaningful work on the altar of expedience or meaningless compliance. Their gaze is fixed on realising their long-term vision, but their focus is intense and relentless on architecting better ways to do better work. In doing so, they build a better world for us all.
Of course, no one is always and forever one of these archetypes, and these are not scientifically derived descriptions—though I expect a few individuals sprang to mind as you read them. People also move between adjacent segments. In our experience, though, they rarely jump across the map. A ‘drifter’ might become a ‘devotee’, but almost certainly not a ‘decreer’. Likewise, it’s hard to imagine a ‘definer’ becoming a ‘dreamer’. The good news is that sometimes people take on an archetype within a specific role, or under a specific manager. So it may be possible to change mindsets by switching them to a different role or team.
On the other hand, if you’re the dynamo and you want to realize a transformation, you may need to get, as Jim Collins calls it, ‘the right people on the bus’. Sometimes, to change people you have to change people. This is why organisational design and organisational learning are indispensable components of a systemic transformation. With the right leadership, too, you can encourage devotees and deliverers to step up and become dynamos themselves.
____________________________
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:

[Background image: Light in hand, Rohan Makhecha on Unsplash]
“Think ‘can if…’ rather than ‘can’t because’.”
____________________________
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.
Discover better ways to do better work.
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 callsDiscover better ways to do better work.
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