Many executives expect: ‘I set the course, you manage the project, they deliver the work.’ But reality feels more like: ‘I expect results, you promise me a deadline, they’re late again.’ How do different subcultures understand each other?
This is Part 2 | Read Part 1 | Part 3
[ Listen to the audio version, read by David Hodes]
In our second of three parts on culture, I want to dig deeper into the dynamics that inform what we see and feel on the surface. As we discovered in the first article, every organisation has a unique culture, generated from how its people adapt to external drivers and build internal coherence. But given that every culture is unique, can we discern certain archetypes within cultures that provide insights to help build our adaptability to changing markets and bind us internally into a more coherent shared vision?
Ed Schein, on whom I draw heavily in this article, notes three major archetypes—the executive, the engineer, and the operator. The executive subculture focuses primarily on financial survival and growth—the equivalent of being in a perpetual war with competitors.
Executives
Strategy guru Michael Porter claimed organisations could only compete on two dimensions—cost and differentiation. As the executive, you get to choose which dimension, and then you’re in a constant war with competitors. It’s hard to trust anyone when you’re leading a ‘war’, so the higher you go in the executive ranks, the more you become the lone hero. You appear in total control, but you cannot get reliable data from below because your subordinates tell you what they think you want to hear. Thus, you increasingly find yourself backing your own judgment, which becomes more and more authoritarian if left unchecked. People increasingly become a necessary evil and not a source of intrinsic value. They appear as ‘resources’ acquired and managed as component widgets to serve the well-oiled machine. They are increasingly no longer whole people who are ends in themselves, but heartless heads and hands to do the boss’s bidding.
Engineers
The engineering subculture refers to those who are required to translate the intention of their executive bosses into projects. The mental model is of a world of elegant machines and processes, working in perfect precision and harmony with minimal human intervention. People are the problem for those who occupy these positions and should be designed out of the system wherever possible. Or, to quote the famous behaviouralist, BF Skinner, ‘The real question is not whether machines think but whether men do’. Nature can and should be mastered with solutions based on science and available technology for the engineering subculture. Their work is to solve puzzles and overcome problems. They do work to create valuable products and services.
Operators
At the bottom of the hierarchy come the operators. This subculture knows that the output of any enterprise results from the action of people. Success, therefore, depends on the operator’s knowledge, skill, learning ability, and commitment. It’s the operators who know how to use the organisation’s core technologies based on their specific experience. They are not as enamoured as the engineers of the elegant machines they dream up. No process is so tightly engineered that human intervention becomes unnecessary, and it is the operators who can learn, innovate and deal with matters as they inevitably go sideways.
Operators are the linkage between the separate parts of the process. It is up to them to find ways to collaborate in teams, communicate effectively, and develop trust with their mates. Management’s role is to ensure they give them the proper resources, training and support necessary to get the job done.
While these three subculture archetypes may vary in their particulars in any given organisation, I suspect you’ll find enough truth in them to admit they exist within yours. Every subculture, however, can still be defined by the rubric of external adaptation and internal integration. So, let’s take a deeper dive into some of the dimensions of culture which would ordinarily pass by our conscious selves and be the invisible fabric of ‘how we do things around here’.
On truth, time and space
Let’s kick off with the question of how people within a culture might define truth. Sounds simple, but not so much. How much of what we regard as truth is simply dogma, based on tradition? Do we rely on the authority of experts and the wise to reveal the truth? What was it about the pandemic that had us surrender our civil liberties to unelected experts because we believed they had the wisdom of prophets? To what extent are we rational and empirical in determining what is true and what is false? Who sets the experiments, who runs the logic and who decides which direction forward? If it’s a marketing decision, is it only marketing who get to run the experiment? Who goes on the lookout for disconfirming data, if anyone? Do we all get to vote on the decision?
Another dimension of culture which we rarely bring to the front of mind is the nature of time and space. Time is a very different commodity to tradie operators clocking on and off from their work on a construction site than to a consultant preparing a report on the impact of environmental legislation on the business case for investment.
You see time very differently when you are in a planning phase of an initiative than when you are executing it. Depending on the circumstance, different people within the organisation have longer horizons of discretion to get their work done. How often do people operating under different time signatures become frustrated with each other? One person’s scurrying around ‘busyness’ is another’s need to run the beast as it’s been designed. What appears to be a leisurely and aristocratic indulgence to some is the carefully considered deliberation of the other. Just pause for a moment when you’re next amongst your colleagues and see if you can observe the metronome beating out the rhythm of their work.
“How often do people operating under different time signatures become frustrated with each other?”
So, as with time, what about space? Sociologists have an expression called the ‘ideal sphere’ around each of us, reserved only for those with whom we have an intimate relationship. It’s between 10 and 40 cm. If a stranger is that close to us, it makes us uncomfortable or anxious. Think about how you feel when you are packed into an elevator or onto a full and busy train. We overcome the physical distance by creating an enhanced psychological space. Moving in this close on the space of another at work can be considered intimidating or creepy.
When we engage in conversations, one on one, we usually have a good sense of personal distance. Somewhere between 45cm and 75cm is felt as being at the proper distance, whereas anything more is considered far. This distance permits a normal or soft tone of voice and is usually accompanied by intense eye contact. Interestingly, these distances are bound in national and ethnic cultures. One can unwittingly feel that a person closing in on the 45cm is ‘in your face’ because of your cultural norms, but they are not violating their own.
When we talk to several people at once, say at a dinner party or a seminar, it usually involves some raising of the voice and less personal focus on any given individual. Our eyes will scan the group, or we will focus on the floor or ceiling. Do your office spaces and meeting rooms feel appropriate for the kinds of meetings you want? If we’re going to meet informally and really get to know each other, the more the room has to be scaled down to allow that to happen. For people seated around a table, its size and shape must be appropriate to feel socially at ease in each other’s presence.
“Do your office spaces and meeting rooms feel appropriate for the kinds of meetings you want?”
A significant contributor to organisational culture is what people think about who they are in the corporate setting and what their role is. A person arriving from a small engineering consultancy into a large mining house could feel like a fish out of water, or alternately as a breath of fresh air. What does the culture allow this person to be? It’s what Schein calls cognitive clarity.
That same person might wonder how their own need for influence and control will be met. How does the organisation manage aggression and disagreeableness? Donald Trump famously set his Atlantic City casinos into fierce competition with each other. The culture in a Buddhist seminary could hardly be more removed from that extreme example.
‘How will the group’s goals allow me to meet my needs and goals?’ is a question we all ask of our workplace, consciously or not. Of course, everyone turns up to work with an intention to get something done. But, in Steve Jobs’s world, there was the well-documented use of his ‘reality distortion field’ superpower. What example does that set for Apple employees regarding what is permissible in the management of intention and will? And what of those organisations who perpetuate the idea that ‘it’s above your pay grade…’.
‘Am I accepted, and can I let down my guard?’ is another question we ask, even if not explicitly voiced. Some organisations are very formal, and a relational distance is maintained to attempt to avoid the messy nature of human affections. What does it mean, though, in an organisational setting to be managing love, that most basic of human emotions? Is your culture a cauteriser of love, or is it expressive and vulnerable? How is intimacy managed?
The more we dig into an organisation’s culture, the more complex it becomes. It is not static but revolves around its historical anchors, reaching back to its founders’ thoughts, behaviours, and actions. In the third and final article on culture, we’ll look into how leaders within an organisation can equip themselves to amplify those aspects of the culture they’d like to see more of and dial down what is harmful.
This is Part 2 of our series on Culture.
Part 1: Cultivating culture
Part 2: Culture – Digging below the surface
Part 3: The Anxieties of Changing Culture
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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.
[Background image: A metronome, Rachel Loughman on Unsplash]
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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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