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Cultivating culture

David Hodes

Legendary management guru Peter Drucker never actually said, ‘Culture eats strategy for breakfast’. But the epigram stuck. In fact, the two are entangled; an effective strategy requires an enabling culture.

This is Part 1 | Read Part 2 | Part 3

[Listen to audio version, read by David Hodes]

But what is culture? When asked this question, many provide the tautologous answer ‘the way we do things around here’. Such a response does not help answer the critical questions of a given organisation’s culture at a given time in its history, and how a productive and generative culture might be cultivated into the manageable horizon.

Much of my understanding of culture comes from the work of Emeritus Professor Ed Schein, who founded the Centre for Organisational Learning at the MIT Sloan School of Management. Schein’s model invites us to look at three levels of culture: artefacts, espoused beliefs and values, and basic underlying assumptions.

The iceberg metaphor is helpful here in that what we see at the top, above the waterline, is the manifestation of what is going on at a much deeper level. You may walk into an office or worksite and look at the general presentation of the work environment. Is it tidy, freshly painted, filled with light, or dark and dingy? Are the spaces intentionally set out like an Apple Store, or is it all rather more like the office of an inundated cohort of junior law clerks? How do people behave towards each other? Are they competitive or collaborative? Bureaucratic or in flow? Cynical or inspired? Family-like or formal? These are artefacts. But even with these, it’s not easy to know what’s really going on, based only on simple observations of what our senses feed to the meaning-making machine of our minds.

Dig a bit deeper, and we are in the realm of espoused beliefs and values. Espoused because they are what we read on the posters, see on the presentations, and hear from the functionaries when we ask questions about ideals, goals, values, and aspirations. When we notice a discrepancy between the espoused values and the actual behaviours, we’re likely to be fed some well-rehearsed rationalisations: ‘Mary’s behaviour is not congruent with our publicly stated value of inclusion, and we have had a lot of complaints about her abrasive and demeaning management style. Still, her personal story allows us to help her more fully activate the better angels of her nature, as, despite everything else, she delivers the results the business is looking for.’

Down at the deepest level, we are into the realm of the unconscious—the same domain that informs the myths we live by. In that domain, we answer the questions about the meaning and purpose of our lives, how we got here, and what we will do with the finite time we have left. In a productive culture, there is a deep congruence of value at all the levels within which we operate: the personal, the team, the organisation, and the society in which we live.

External adaptation and internal integration

Arriving at such a state of harmony within an organisational setting is never easy. We have two significant challenges to overcome: external adaptation and internal integration. Before exploring these two challenges in more depth, it is worth quoting Schein’s definition of culture in full:

‘The culture of a group can be defined as a pattern of shared basic assumptions learned by a group as it solved its problems of external adaptation and internal integration, which has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.’

In other words, what we learn about solving the problems of external adaptation and internal integration and how we examine the assumptions that inform that learning is of the essence to culture formation.

External adaptation includes understanding how we get to play our game within the markets in which we compete. We need to articulate our mission and strategy in a way that all critical stakeholders understand. We must embrace the question that asks what the fundamental problem is that we solve for those who consume our products or services? Given our mission, what is our goal? At least how much of what, by no later than when? How must the accountability hierarchy be constructed to best serve the processes which deliver on the mission? What means will we need to secure to accomplish our mission? How is the division of human, financial, material and information resources determined and allocated? What will we measure, and how could those measures be used to control progress towards our stated goal? How will we develop a consensus on the when and what of course corrections? What are the appropriate remedial or repair strategies to be used if goals are not being met?

Internal integration proves a more challenging arena for us to understand. It begins with the idea of creating a common language, where words and conceptual categories have shared meaning. As an example, think of the number of acronyms we demand a recruit learns before they come to readily understand the local dialects. The idea of internal integration begs the question of the extent to which the integration applies. What is the boundary for inclusion, and who, then, is in or out? By what criteria is membership determined?

Once we know the group’s boundary, each must work out its pecking order, criteria, and rules for how someone gets maintains and loses power and authority. Consensus in this area is crucial to help members manage feelings of aggression. If there are no rules around the exercise of power, we trigger that primal aggressive response associated with unfair authoritarianism.

How is the game played?

Over time, every group must work out its ‘rules of the game’ for peer relationships, relationships between the sexes, and how openness and intimacy are handled in managing work. Consensus in this area is crucial to help us define trust and manage feelings of affection and love. How much damage has been done by the office affair? It’s not easy to navigate from the locker room to the board room. In brief, norms must be developed around trust, intimacy, friendship, and love.

Included in the theme of fairness at work, to develop a productive culture, we must come to share an understanding of what behaviour is heroic and what is unacceptable. Once we know these behaviours, we must achieve consensus on how we reward what is good and punish what is terrible.

And then there is the realm of the unexplainable—those events that fall outside the boundary of the day-to-day which challenges our well-worn nostrums of habit. How do we give meaning in a way in which group members can respond to them without excessive levels of anxiety?

Coming to meaningfully understand all these aspects of external adaptation and internal integration goes well beyond simply taking stock of the artefacts of culture, and even the deeper level of the espoused beliefs and values. To fully understand the culture of a group, we would need to equip ourselves with the competencies of a social anthropologist. Having said that, I have found the Competing Values framework offered by Cameron and Quinn helpful in getting an early read of the four archetypes they have in their model: Clan, Adhocracy, Hierarchy and Market. This model, illustrated in the diagram, looks at the competing values associated with an internal or external focus and whether stability and control are most essential or flexibility and discretion.

No organisation is at any given time any one of these archetypes, and there is always a natural tension between where the organisation is, compared to where the members would like it to be. There is an ongoing dynamic between the internal and external focus and whether the emphasis is on integration or differentiation. Many factors could influence the choices which value stability and control over flexibility and discretion or vice versa.

Even acknowledging that these competing values are forever in the dance of change, shifting the centre of gravity from one cultural archetype to another quadrant is far more challenging to accomplish than many in the field care to acknowledge. In the same way that a nick in a sapling is visible in the grown tree, so too does the influence of the founders run within the organisation’s DNA throughout its life.

It takes a very long time to learn to succeed in any given endeavour and the habits formed from learning how to succeed are not readily surrendered. We are far more ready to acknowledge when markets change, and our focus and comfort is found in what needs doing in the external competitiveness arena. It is far more challenging and takes much longer than we would ordinarily allow to co-create a new way of being in all the areas of internal integration outlined above.

In my next article, we’ll explore more deeply the subcultures present within most organisations as well as dig into the kinds of mental models we carry when assessing our place within a culture.

This is Part 1 of our series on Culture.

Part 1: Cultivating culture
Part 2: Culture – Digging below the surface
Part 3: The Anxieties of Changing Culture

____________________________

What’s next?

The change to using Theory of Constraints (TOC) as an underlying operating system is both profound and exhilarating. We’ve developed the Systems Thinker Course to bring the ideas into your organisation.

  • View the Systems Thinker Course Guide (no email required to download)
  • Join us for the Systems Thinker Foundations Workshop (we run this FREE workshop once each month)
  • To find out more about these, or any of our services, simply schedule a call
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  • MedTech

Validating medical device concepts before major investment

David Hodes

Concept validation

A concept can look convincing in a presentation and still make an important task harder. A patient may misunderstand an indicator. A clinician may need information the design does not provide. A promising workflow may depend on support unavailable in the intended setting.

These problems become more expensive when the organization discovers them after committing to architecture, tooling or a launch plan.

We must ask how effectively concepts are validated before significant resources are committed. Patient Centered Design treats this as a learning discipline: turn ideas into testable solutions rapidly using low fidelity prototyping, put them in front of relevant users and gather evidence about whether they improve the outcomes that matter.

“A convincing presentation shows what the team hopes will happen. A useful test reveals what people actually do.”

Begin with a question that can change the decision

A prototype without a learning objective can generate interesting comments while leaving the key decision unresolved. Start by identifying what must be true for the concept to succeed.

Does the patient intuitively understand the required action without explanation? Can the professional recognize when the result is ready to use? Does the proposed approach fit the work surrounding the task? Will people take meaningful steps toward adoption?

State the assumption and the evidence needed to assess it. Agree what would support proceeding, what would require revision and what could make the concept unviable. Gather quantitative data along with qualitative verbal feedback.

Prioritize questions with substantial consequences for the investment. An attractive enclosure deserves less attention than an unresolved issue that could prevent safe or practical use of the whole solution.

Choose the simplest useful representation

A picture is worth a thousand words. A simple user experience prototype is worth a thousand pictures. Choose artifacts that maximize learning with the least effort. The appropriate artifact depends on what the team needs to discover.

A sketch may help users explain how they interpret a proposed interaction. A physical mock-up may expose handling difficulties. A simulated interface can support a sequence of tasks. A more complete prototype may be necessary to examine timing, feedback or combined interactions.

Build enough realism to test the assumption accurately. Excessive detail can consume resources without improving the evidence, while insufficient fidelity can conceal the issue being investigated.

Make limitations clear to participants and observers. A manually simulated function may help test an experience, but it does not establish that the technology can deliver that function reliably.

Recruit people who represent the intended use

Patients and healthcare professionals can differ in experience, confidence, physical ability, responsibilities, and access to support. Those differences influence whether the concept helps them complete the job.

Define the participants and contexts relevant to the test. Include people whose circumstances could expose difficulties the development team has overlooked.

A familiar expert may work around a confusing interface that challenges a new user. A clinician from a highly supported center may assume resources unavailable elsewhere. Research needs to reveal these dependencies.

Match the study to its purpose. Exploratory sessions can identify problems and guide iteration. They do not automatically establish population-wide performance or replace the evidence required for later design validation.

Create an Experience Café around real tasks

An Experience Café gives participants a structured opportunity to encounter concepts and talk about their experience. Its value comes from the quality of the scenario, observation and follow-up questions.

Set up situations that reflect what the person is trying to accomplish. Let participants interact with the artifact rather than rely solely on a demonstration by its designer. Build rough and rapid.

Assign roles to facilitators and observers. Agree how comments, actions and difficulties will be captured. Keep the session focused on learning rather than defending the proposed solution. Hold a conversation around the prototype. “Can you show me how you would use this?” “Tell me what you are thinking here.”

Ask participants to explain what they believe is happening and what they would do next. Observe where the concept supports that understanding and where they hesitate, improvise or seek help.

Listen without teaching away the problem

A facilitator can unintentionally make a weak concept appear successful by explaining each step or supplying missing information.

Use neutral prompts and allow participants to reveal their interpretation. When assistance is necessary, record it along with the point at which the person became stuck.

Follow observations with questions about purpose and reasoning. What did the participant expect? Which information did they look for? Why did they choose that action?

Separate a preference from evidence about task performance. “I like this one” may reflect appearance or familiarity. Successful completion, appropriate interpretation and manageable effort provide a stronger basis for assessing whether the concept addresses the need.

“Every explanation the facilitator must supply is a question about what the design expects the user to know.”

Examine the complete experience

The product interaction belongs within a wider job. Test preparation, readiness, execution, monitoring and what follows, wherever these activities affect the concept’s value.

A device may work well once configured while setup introduces avoidable complexity. A result may be easy to view while the professional still needs to transfer it manually before acting.

Include relevant dependencies on caregivers, staff, information and other systems. Investigate whether the concept reduces burden for one participant by increasing it for another.

Use realistic scenarios appropriate to the development stage. Important exceptions and recovery steps deserve attention alongside routine success. An incomplete or interrupted task can reveal weaknesses that a carefully guided demonstration leaves hidden.

Make cognitive burden visible

Ease of use involves what a person must notice, understand, remember, decide and physically do. A tidy interface can still demand substantial mental effort.

Human performance depends on limited attention, working memory and feedback. Examine how the concept supports those processes during a task.

Does it make the relevant information perceptible? Can the user understand its meaning? Is the next action clear? Can they recognize whether that action succeeded?

Look for unnecessary steps, demands to remember information across screens and alerts that interrupt without helping a decision. The best change may simplify a sequence or improve feedback rather than add another feature. Confirm its effect through observation and appropriate measures.

Measure effort alongside task success

Choose measures that reflect the priority outcome and the study’s purpose. These may include completion time, errors, requests for help, repeated actions or failure to notice important information.

Subjective workload measures can complement observed performance. NASA Task Load Index can help structure participants’ assessment of workload, while PURE provides an expert assessment of the effort required to complete tasks. Satisfaction ratings on a Likert scale can be used to compare concepts directly with each other and a baseline solution.

Do not treat one measure as a complete account of usability. Faster completion may accompany misunderstanding. A participant may complete the task correctly while reporting effort that makes repeated use impractical.

Interpret results together and examine the conditions under which they occurred. Record the limitations so decision makers understand what the test has established.

Test demand separately from technical feasibility

Pretotyping examines whether people take meaningful action toward using or adopting an idea before the full solution exists. It addresses a different question from whether a working product can be engineered.

A clearly described concept, service simulation or expression-of-interest process may provide evidence about engagement. The strength of that evidence depends on the action required and the conditions surrounding it.

A click demonstrates less commitment than a substantive implementation conversation. Neither establishes clinical efficacy or successful device use.

For medical concepts, keep representations accurate and make the test status clear. Interpret behavioral evidence alongside clinical appropriateness, access requirements and the responsibilities of the people making adoption decisions. Interest alone cannot establish that the solution should proceed unchanged, particularly when workflows in the clinical setting are involved.

Refine the value proposition with evidence

A value proposition explains which customer the concept serves, the job it supports and the difficulties it intends to reduce. It should connect directly with the outcomes identified through research.

Compare that proposition with the evidence from concept tests. Did participants experience the intended benefit? Did another difficulty become more important? Did the concept require assumptions that the intended setting cannot support? Did the concept do something better than a competitor’s current solution?

Capture both positive and negative findings. Use them to revise the concept, the proposition or the team’s understanding of the need.

Then test the important changes. Iteration should answer a question left open by the previous round. Repeating sessions without changing the artifact or research objective can accumulate comments while leaving uncertainty untouched.

Keep early findings within their proper limits

Early concept validation supports decisions about direction and investment. It does not establish all the evidence needed for a finished medical device.

Technical performance, reliability, clinical benefit and intended-use safety require appropriate subsequent work. A convincing simulated experience may depend on functions the team has not yet demonstrated.

Make these boundaries visible in the decision record. State who participated, what was tested, the conditions, findings and unresolved issues. Explain how those findings affect the next commitment.

Overall, having a “winning concept” in hand, backed by user Experience Café data along with user needs in the form of outcome statements formally structured with a direction of improvement and unit of measure, sets a development team up for success. The outcome statement user needs provide a solid foundation for the design history file.

Rapid prototype experience testing gives the team answers to key decisions and sets a target to pursue early on. This results in faster development cycles, more robust regulatory submissions, and better returns on investment spending.

A Value Management Office can connect this learning with resources and stage decisions. Testing should help the organization commit at a pace justified by evidence and concentrate effort on the uncertainties that govern progress.

“Early validation creates value when it changes the concept or the commitment before an unresolved assumption becomes expensive.”


What comes next

Examine one proposed investment. Which assumption could defeat the concept, and what is the least costly credible way to test it?

Prepare an appropriate artifact, involve representative users and observe meaningful tasks. Review the evidence, revise the concept and record the next learning decision. This gives Patient Centered Design a practical route toward solutions people can successfully use and organizations can responsibly develop.

READ MORE

  • MedTech

Developing medical device concepts around patient needs

David Hodes

A development team can become committed to a concept before it has seriously considered an alternative. The idea is familiar, a senior sponsor favors it or an available technology makes it attractive. Detailed engineering begins while the reason for choosing that approach remains largely untested.

Concept engineering provides a more disciplined basis for commitment. It develops several viable approaches, compares them against important needs and combines their strongest elements where doing so improves the solution.

Within Patient Centered Design, the purpose is to identify a concept that can help patients and healthcare professionals accomplish their jobs successfully. Question 2.1.1 examines the effectiveness of that work.

“A winning concept earns its place by addressing important needs and surviving comparison with credible alternatives.”

Start with a problem the team agrees on

Concept work begins with a concise problem statement and an agreed objective. Both should describe the progress the intended users need, rather than assume the answer.

An illustrative problem might concern a clinician’s difficulty identifying whether the information needed for a treatment decision is complete. “Build a new dashboard” commits to one response before exploring the problem.

Clarify the users, operating context and desired outcome. Review the patient journey and the clinical work surrounding the interaction. Establish which unmet needs the concept must address.

Resolve major differences in interpretation before the selection exercise. A mechanical engineer, clinician and commercial leader can otherwise compare ideas while quietly applying different definitions of success. Shared language makes their conversation more useful.

Bring priority needs into the criteria

Concept selection needs criteria grounded in research and requirements. Include the outcomes patients and professionals consider important, particularly those existing approaches satisfy poorly.

Then identify necessary capabilities and constraints. Relevant considerations may include safety, reliability, usability, manufacturing, service requirements, implementation and the resources available to develop the solution.

Separate mandatory conditions from characteristics that permit tradeoffs. A concept that cannot satisfy a necessary safety condition needs resolution or rejection; attractive performance elsewhere cannot compensate for that failure.

Define the criteria clearly enough for consistent comparison. “Easy to use” leaves the team guessing. The number of required actions, time to complete an activity or ability to recognize readiness can provide more concrete grounds for conversation, depending on the need.

Generate options before narrowing the field

Concept engineering encourages broad idea generation, with constraints applied more deliberately during selection. This gives the team room to consider alternatives before familiar solutions dominate.

Use sketches and short descriptions to make ideas visible. Invite different functions to contribute approaches, concerns and connections the team might otherwise miss.

The concepts should represent meaningful alternatives. Several versions of the same preferred design may leave the underlying assumptions untouched.

Explore how the required function could be achieved differently. Could information arrive earlier? Could preparation become simpler? Could a service change remove work the proposed product was intended to automate?

Make concepts understandable enough to compare

A concept should communicate its operating principle, important interactions and dependencies. A simple drawing can expose differences that remain hidden in a verbal description.

Explain what the patient or professional would do, what the system would provide and what supporting resources would be required. Include the activities before and after the visible product interaction.

Build enough detail to support the decision at hand. Early concept selection does not require complete engineering specifications, but an appealing image alone gives little basis for comparison.

Record what is known and what is assumed. If one idea appears stronger because its description omits difficult tasks, the matrix will reward an incomplete account of the solution. Consistent descriptions support a fairer evaluation.

Use a simple comparison matrix

The Pugh matrix provides a structured way to compare concepts. List the criteria as rows and the candidate concepts as columns. Choose a reference concept, known as the datum, against which alternatives will be assessed.

For each criterion, judge whether a concept is better than, similar to or worse than the datum. The simple notation is positive, same or negative.

Discuss the basis for each rating. Record supporting evidence and unresolved questions. The matrix makes differences visible and gives the team a shared place to examine them.

Totals can help identify promising candidates, but they should not make the decision automatically. The significance of a weakness depends on the criterion involved. Several small advantages may leave a concept unable to address its most important requirement.

“The matrix is useful when it exposes the reasoning behind a choice and the evidence still needed to defend it.”

Match the method to the available evidence

Early conversations often rely on incomplete information. Simple comparisons can be more useful than elaborate scores that suggest a level of precision the team does not possess.

Weighted methods may help when criteria genuinely differ in importance. Paired comparisons can support more structured judgments about relative priority. When measured engineering performance is available, use those data directly in the evaluation.

Choose the method for the decision and evidence, rather than adding complexity by default. Explain how weights or ratings were established and which assumptions could change the result.

Check whether the leading concept remains attractive under reasonable changes to uncertain judgments. A decision that reverses after a minor rating adjustment deserves closer examination before the organization makes a substantial commitment.

Look for stronger combinations

Hybridization is a central part of concept engineering. A concept with several strengths may also have a weakness another option handles well.

Examine whether the useful elements can be combined into a stronger approach. For an illustrative monitoring solution, one concept may support straightforward preparation while another provides clearer feedback when a connection fails.

A hybrid might preserve both benefits, but it needs its own evaluation. Combining features can introduce new interfaces, added complexity or conflicting operating requirements.

Redraw the combined concept and reassess it against the criteria. Investigate whether it actually removes the weakness or merely moves the burden elsewhere. The aim is a coherent design whose interactions work together, rather than an accumulation of everyone’s favorite features.

Manage disagreement as a source of learning

Concept selection brings technical judgment, professional experience and organizational interests into the same conversation. The quality of that conversation affects the outcome.

Agree on meeting ground rules and use a team with relevant expertise across functions. Ensure that a strong personality or senior title does not become a substitute for evidence.

When disagreement cannot be resolved, capture the question and define an action. Assign an owner, the evidence required and a completion date. An independent facilitator can help when team dynamics obstruct useful comparison.

The method can make judgments more transparent, but it does not eliminate subjectivity. Leaders should expect the team to explain its reasoning and show how important uncertainties will be resolved.

Test the assumptions that could defeat the concept

The leading idea may depend on uncertain technical performance, user behavior, supplier capability or implementation conditions that significantly affect time to market. Identify those dependencies before detailed development absorbs significant resources.

Plan focused experiments, research or prototypes to address them. Match each activity to a question that could change the selection decision.

If a concept depends on clinicians adopting a new preparation routine, a technical bench test will not establish that assumption. If it depends on a material performing under particular conditions, user enthusiasm will not resolve the engineering question.

Prioritize uncertainties with serious consequences for the concept’s viability. Early learning should help the team avoid expensive redesign while preserving options until the relevant evidence is available.

Select a direction with a clear explanation

At this point in the design process, using patient and healthcare professional journey mapping satisfies the Empathy stage of Design Thinking. Understanding the jobs to be done and desired outcomes satisfies the Define stage of Design Thinking. Concept engineering at its core is a practice that ensures the best solution direction is chosen before significant expense is incurred and satisfies the Ideate stage of Design Thinking.

With a selection of “winning concepts” in your pocket, complete the Design Thinking stages by rapidly prototyping and testing solutions with customers to gather data on which concepts your customers desire most. The Design Thinking stages provide an explanation of why a solution is preferred and a record of why alternatives were not chosen.

Retain the criteria, important comparisons, hybridization decisions and unresolved risks. This record helps future teams understand the consequences of a proposed change.

Selection establishes a direction for further learning and development. It does not prove that the solution meets user needs or performs safely in practice. Concept validation and subsequent engineering evidence must support those conclusions.

Keep the relationship with the original needs visible. A chosen architecture can gradually lose important benefits as specifications and implementation choices evolve. Traceability helps the team notice when a tradeoff undermines the reason the concept was selected.

Connect concept decisions with enterprise priorities

The Voice of Business and Voice of Technology should inform selection alongside customer evidence. A concept needs a realistic development route and an operating environment capable of supporting it.

A Value Management Office can connect these choices with resources and portfolio priorities. Systems thinking helps the team examine whether the proposed improvement addresses a constraint governing patient access or successful use.

Evaluate the complete contribution. A technically impressive device can introduce training, service or clinical work that limits its benefit in the wider pathway.

“Concept engineering should leave the organization with a reasoned choice, a manageable learning plan and a clear connection to patient benefit.”


What comes next

Review one current concept decision. Can the team show credible alternatives, agreed criteria, the basis for selection and the assumptions requiring further evidence?

Bring the relevant disciplines together, compare options and examine stronger combinations. Then test the uncertainties that could change the decision. That is how Patient Centered Design builds a defensible route from important needs to better products.

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