Organisation | People
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When I was in Year 3, I won a book prize for topping my class. The book, called How Things Work, had pictures of steam engines, telephone exchanges and aeroplanes; motor cars, power stations and printing presses. It fired my imagination and curiosity for how things work, which has never diminished.
Technical systems, like the ones described above, can be understood through the laws of physics and the axioms of mathematics. Social systems are another matter. Each of us is far more complex individually than any machine, and when you put us together in an organisation to accomplish a common goal, that complexity increases exponentially.
So, what means do we have at our disposal to understand how these complex organisations work? How do we get beyond the clichés of purely behavioural approaches to the challenges of managerial leadership and come to an understanding of what separates the great from the good and the indifferent from the failures?
Before we do, let me confess that when I first discovered the Theory of Constraints (TOC), fairly early on in my work career, it had immense appeal to my natural proclivities and the training I’d had in mechanical engineering. The ‘inherent simplicity’ Goldratt had discovered fitted in very well with my worldview, and I thought it simply a matter of time before everyone was doing their work using a constraint-based paradigm. I even left my secure job to start a consultancy in TOC as I didn’t want to miss the boat. More than two decades later, I have some better-formed ideas about why it is so difficult to bring this new way of working into the world, based on the principles of systems thinking.
What helped me on that journey of understanding was the work of Elliott Jaques, a pioneer in the field of Stratified Systems Theory and author of the seminal book Requisite Organisation. Jaques was born in Toronto in 1917 and died in 2003. He studied medicine and psychoanalysis. Through his work, which analysed tens of thousands of positions in a wide diversity of organisations, he empirically established a strong correlation between mental processing ability (cognitive capacity), time horizon of work and complexity.
“Different levels of work have as different a nature in terms of modes of thinking as, by analogy, water is different to steam”
Jaques made the point that there are strata of work in any substantial organisation, and that these strata are ‘as required by nature’. Thus, the requisite organisation is not seen as being optional, but rather, as he puts it, there are only requisite organisations and degrees of variance from the requisite order:
Misconceptions lead to inept people systems, which produce unfortunate behaviours, which lead to one-sided, negativistic view of people at work, which leads to new inept people system fads, which produce unfortunate behaviours, which…
He maintained that rather than the traditional 4D world of human life—three spatial and one time-based, there were in fact three spatial and two time dimensions. There is Chronos, which we are all familiar with as time measured by a clock. But there is also Kairos (also from the Greek), the axis perpendicular to the Chronos axis in the diagram below. At any given point in time, Kairos is informed by the memory of the past, perception of the present and intention for the future.
Cognitive ability is that quality of mind which defines the outer limit of the horizon of intention. That is, not some vague notion about a future vision, but the actual mental processing ability to apprehend the future, understand the complexity associated with bringing it into being and having the wherewithal to exercise judgement and discretion in overcoming obstacles on the way to that horizon.
Jaques discovered through his vast research that different levels of work have as different a nature in terms of modes of thinking as, by analogy, water is different to steam. He found that the time horizons of the levels of work were remarkably consistent—regardless of the specifics of the industry or organisation within it.
These levels of work, he called modes, and they break down as follows:
Mode 1 – 1 day to 3 months
Mode 2 – 3 months to 1 year
Mode 3 – 1 year to 2 years
Mode 4 – 2 years to five years
Mode 5 – 5 years to ten years
Mode 6 – 10 years to 20 years
Mode 7 – 20 years to 50 years
(For Mode 8 and beyond we’re talking about ideas that change the world, such as those of Galileo’s and Einstein’s, or Gandhi’s and Martin Luther King’s, which go beyond the realm of organisations.)
Interestingly, the cognitive classes of the strata repeat in a fractal way. Mode 1 is the frontline worker, Mode 2 the supervisor, Mode 3 the manager and Mode 4 the executive. So for the frontline worker at Mode 1, the object of the work is completion of the task at hand. At Mode 2, the work is supervising the tasks at Mode 1. And so on. At Mode 5 things start to repeat where, for the CEO of the strategic business unit, the object of the work is everything contained within that business unit. And the Group CEO at Mode 6 is accountable for the superordinate organisation comprised of multiple strategic business units. This stratified systems view is analogous to music where each note of a scale repeats at the octave. And in fact Jaques call the repetition of these four fundamental cognitive classes ‘quadraves’.
The work at the level of Modes 3, 4, 5 and 6 is as follows. Someone operating at Mode 3 will be running and improving an extant system of management. It’s what the Japanese Lean practitioners call kaizen—‘change for better’, or continuous improvement. Mode 4, however, is distinguished by the fact that the work involves the design of entirely new systems of managerial leadership—what the Japanese call kaikaku, ‘radical change’, or transformation. When operating at Mode 4, you are working on a hypothesis of what the future might be, two-to-five years from now, and reckoning on all that is necessary and sufficient to bring that future into being. Mode 5 would be asking strategic questions about new lines of business, geographies and markets. Mode 6 might be charged with fulfilling the intention to establish a worldwide chain of businesses, organised in regions within every continent.
“As long as the person acts within the socially accepted bounds of temperament, effectiveness is more important than likeability.”
There’s no getting away from the fact that most organisations have too many levels, and some have strata missing. No organisation can ascend beyond the level of work practised by the most senior person in the organisation. If that senior-most person cannot operate at the level required by the role, it will cause compression in the roles below, with competent people frustrated that they cannot be effective in exercising their discretion and judgement suited to their capability. Alternately, if a managerial leader occupies a role which is too big for him or her, then they will feel stressed, ineffective and unworthy of the trust placed in them when they took on the role in the first place. If a person is in the right-sized role for their cognitive ability, they operate in flow and have the opportunity to get great joy and reward from their work.
Having the right person in a role is thus not merely a function of their experience, knowledge or affability. One doesn’t have to be agreeable to be a fine managerial leader. As long as the person acts within the socially accepted bounds of temperament, effectiveness is more important than likeability.
What Jaques’s work promotes is the idea that in any managerial accountability hierarchy, success is predicated on there being a tight fit between accountability for getting the job done and authority over the resources required to do so. Understanding the nature of levels of work means there is a much richer set of conditions to overcome the all too frequent mismatch of accountability and authority.
In discovering the work of Jaques I felt I’d finally been given the key to understanding how organisational hierarchies work and how they can be designed to work better. It’s like being given a pair of X-ray specs to look at the organisation’s skeletal structure and noticing whether or not it is ‘requisite’. So often, in the early days of my enthusiasm for TOC I would hear vacuous statements such as ‘you have to have buy-in from the top’, or even more perniciously that hierarchy was in and of itself not a good thing and that the organisation should be ‘flat’. I now know that without a solid understanding of the pioneering work of Jaques I would always be running blind, dependent on dumb luck for results. A Requisite Organisation is a necessary condition of reliably and sustainably unleashing the power and promise of systems thinking.
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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:
- download the brochure (no email required)
- schedule a call
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[Background photo by Bernard Hermant on Unsplash]
“In a hierarchy, every employee tends to rise
to his level of incompetence”—Laurence J. Peter
Understanding the Jobs Patients Need Doing
A patient may ask for a smaller device, a clearer display or an easier app. Those requests matter, but they leave a deeper question unanswered: what is the person trying to accomplish, and why does the current approach make it difficult?
Someone using a monitoring device may want to understand whether their condition is changing, decide when to seek help or manage daily activities with greater confidence. The device is one means of achieving that outcome.
A powerful question asks how well your organization understands the jobs patients are trying to get done. A strong answer connects patient research with clearly defined outcome statements that become the formal user needs your teams use to build the design history file. Outcome-based user needs are easier to validate, flow more easily into design requirements, and result in faster time to market.
“A feature request describes a possible answer. Understanding the patient’s job to be done sets your design team up to deliver a better solution faster.”
Define the job from the patient perspective
A useful job statement describes an activity the patient needs to accomplish in a relevant context. It should remain understandable without naming your product or preferred technology.
“Use our app every day” describes behavior your organization wants. “Provide a way to recognize when a change in my condition requires professional advice” describes the outcome a patient actually desires.
The distinction affects research. If the team starts with the app, it will ask how to improve screens and interactions. Starting with the job opens questions about information, confidence, timing and support. The best solution may involve changes beyond the app.
Define a scope the team can investigate. “Live a healthier life” expresses an aspiration but is too broad to guide detailed engineering decisions on its own. “Minimize the time it takes to find a solution to my health concern without needing to talk to a doctor or call someone” gives a team a direction, a measure, an object of control and contextual clarifier(s).
Distinguish the job from the journey
Journey mapping shows how people move through a particular care pathway. Job mapping examines what they must accomplish to achieve their purpose, including the work surrounding the interaction with your solution.
The two perspectives complement each other. A journey may show that a patient waits for follow-up. The job perspective asks what they are trying to understand or decide while waiting.
This matters because current processes can become embedded in the team’s assumptions. Patients may need a reliable way to recognize an important change; they do not necessarily need the exact sequence of activities currently provided.
Use the journey to understand context and dependencies. Use the job to examine whether a different approach could help the patient achieve the desired outcome more effectively.
Study daily life where it happens
Patient research begins with observation and empathy interviews at the Gemba, the place where the activity actually occurs.
For patients, that place includes the home and the settings in which they manage health alongside ordinary responsibilities. Ask people to demonstrate routines, explain decisions and describe recent experiences.
Observe what they do. Immerse yourself in the circumstances surrounding the activity. Engage through questions that let them explain their purpose in their own language.
A person may say that managing treatment is straightforward while observation reveals multiple reminders, improvised storage or reliance on a partner. Those arrangements can reveal effort and uncertainty that have become familiar enough to go unreported.
The aim is to understand the why your solution will win before making any decisions about what your solution will do. Customers will want your solution because of the outcomes it gives them, not because of what you made.
Recruit for differences that affect the job
Patients with the same diagnosis may struggle with different parts of an activity. Differences in confidence, experience, resources and support can change how they define success.
Recruit participants whose circumstances reflect the population you intend to serve. Include relevant variations in health literacy, technology familiarity, physical ability and access to care. Are you targeting the tech savvy millennial, a busy parent trying to run a family with four kids or a retiree living in a managed healthcare facility?
Research should also examine emotional and social needs. A patient may want reassurance about managing a task alone or worry about drawing attention to a condition. Keep these needs visible alongside functional outcomes without assuming one design choice resolves them all.
Examine the complete job
The job mapping framework divides a job into eight recurring steps. These steps prompt investigation beyond the most visible interaction.
- Define. Establish what the patient needs to achieve and the circumstances that matter.
- Locate. Establish how the patient will find the information, materials or support required, including your solution.
- Prepare. Uncover how the patient will arrange the environment and resources for the job to be done.
- Confirm. Understand how the patient will make the decision to go forward with your solution and determine whether everything is ready for the intended next action steps.
- Execute. What outcomes matter to the patient as they get your solution and start using it. Often this is the ONLY job step the team looks at.
- Monitor. How will the patient assess and know for sure your solution is progressing successfully.
- Modify. Rarely do things work perfectly on the first try. Identify outcomes that are important to the patient when adjustments to the approach are needed when conditions or results require it.
- Conclude. Complete the set of outcomes by understanding how the patient completes the activity or prepares to repeat it.
Apply these prompts to actual patient work. Some steps may recur or overlap. The map should help the team discover needs, rather than force experience into an artificial sequence.
“The most useful innovation may help a patient prepare, recognize an exception or recover confidence before it changes the device itself.”
Turn patient language into outcome statements
Interviews generate verbatims: patients’ own descriptions of experiences, difficulties and expectations. Preserve that evidence, then interpret what each statement reveals about the job.
An illustrative verbatim might be, “I keep checking because I don’t know whether the reading matters.” The desired outcome may concern recognizing a meaningful change or understanding what action is appropriate.
A structured outcome statement identifies the direction of improvement, a measure, the object being controlled and relevant context. For example: “Minimize the time required to determine whether a change in a reading requires contacting my care team.”
Ask the team if there are uncovered outcomes that can set your solution apart related to how it is purchased, installed, received, set up, learned with training support, transported, maintained, upgraded, replaced or disposed.
This formulation gives research and design a clearer target. It does not establish a clinical threshold or promise that a device can safely make the decision independently, but often the features that will make your solution “easy to use” or set you apart will come from these outcome statements.
Preserve meaning as you organize the evidence
Several comments may describe the same need. One comment may contain multiple needs. Review the evidence carefully before combining it into a set of outcomes.
Remove duplication, separate distinct outcomes and retain links to the original accounts. Use plain language that patients can understand. Avoid embedding a particular feature in the statement.
Check the interpretation with participants or other appropriate reviewers. “I want fewer notifications” might mean reducing irrelevant interruptions while preserving important information. Treating it as a demand to suppress all alerts would misrepresent the need.
The output should be a coherent set of outcomes organized by job step. Completeness and clarity matter but typically it is ideal to have at least 100 and no more than 200 outcome statements for the team.
Measure importance and satisfaction separately
Qualitative research discovers needs and explains them. Quantitative research helps determine how widely they matter and how well existing approaches satisfy them.
Ask patients to rate the importance of each outcome and their satisfaction with their current ability to achieve it. Make the reference situation clear so respondents evaluate comparable experiences.
A high scoring importance outcome with low satisfaction deserves investigation. High satisfaction may indicate that the need is already well served so the team can use what already exists and put more time in creating innovative solutions to high importance low satisfaction outcomes. Low importance can reduce its priority, although clinical safety requirements cannot be dismissed through a popularity score.
Use a research design appropriate to the intended population. The outcome statements are easy to rate on a five point Likert scale. Choose population quantitative research in alignment with your target persona groups.
Identify opportunities within patient segments
The Outcome Driven Innovation approach uses importance and satisfaction to identify underserved outcomes. Its opportunity calculation adds importance to the positive gap between importance and satisfaction.
Use compatible scales and a clearly defined calculation. Interpret the result alongside the underlying responses, research quality and the clinical context.
Examine differences between groups. An outcome that appears adequately served overall may remain difficult for patients with less support or a different level of experience.
These differences can reveal meaningful segments based on unmet needs. They help the organization avoid treating demographic similarity as evidence that patients need the same solution. Prioritization should retain enough detail to explain whose outcome the proposed improvement will change.
Connect outcomes with development decisions
A target product profile brings the priority outcomes together with business goals, available technology and other relevant requirements. It helps the team agree what success should look like before committing to a concept.
Translate patient outcomes into design inputs and measurable requirements while preserving traceability to the evidence. Define which questions remain uncertain and what research or testing will resolve them.
Evaluate concepts against the outcomes they are intended to improve. Ask whether the proposed approach reduces effort, uncertainty or difficulty for the relevant patients and results in higher satisfaction scores than the baseline solution. A favorable reaction to an attractive prototype provides limited evidence unless the team can connect it with better execution of the job.
Keep patient progress connected to system performance
A priority patient need may involve work performed by a clinician, caregiver or service provider. Investigate those dependencies before deciding that a product change will solve the problem.
The Theory of Constraints helps identify where improvement can change the performance of the wider pathway. A better patient interaction can have limited effect if access to essential support remains constrained.
A Value Management Office can coordinate the initiatives needed to address these connected issues and keep investment aligned with patient outcomes.
“Patient insight becomes useful design evidence when the team can show which outcome matters, who struggles with it and how the solution improves it.”
What comes next
Use patient jobs to be done to review one priority patient job. Can your team state it clearly, map its steps and demonstrate which outcomes are highly important and poorly satisfied?
Start with observation and patient conversations. Build and validate the outcome statements, measure priorities and test concepts against them. That discipline gives Patient Centered Design a practical foundation for better products and more lives changed for good.
The healthcare professional: a hidden constraint in patient flow
A healthcare professional can recognize the value of a medical device and still struggle to incorporate it into care. The referral may be incomplete. Diagnostic evidence may arrive late. Preparation may require extra staff. Follow-up may introduce work that nobody has agreed to own. Managing the patients before and after may require additional staff which adds risk to the business side of the practice.
Those difficulties affect the clinician’s ability to help patients reach and benefit from your solution. They deserve attention during development and throughout deployment.
The purpose is to understand how professionals encounter, assess, recommend and use a solution, and what constraints they encounter in using your solution.
A useful map connects the professional’s experience with patient flow. It helps the organization identify where support, coordination or design changes can improve the delivery of care.
“Clinical enthusiasm cannot create the time, information or supporting capacity needed to deliver a therapy.”
Identify the professionals who shape the pathway
Healthcare professionals perform different jobs at different stages. A referring practitioner, diagnostic specialist, interventional physician, nurse and educator may all influence whether the same patient receives successful care.
Define which groups participate in your pathway and what each contributes. Who recognizes the need? Who establishes eligibility? Who performs the procedure? Who trains the patient? Who monitors outcomes and manages exceptions? Who manages insurance?
Include people whose work makes these actions possible. Coordinators, technicians and administrative staff may arrange appointments, prepare equipment or assemble records. Their contribution can govern whether clinical time is used effectively.
The map should make dependencies visible across roles. It should also clarify which actions fall within your organization’s influence and which require collaboration with care providers or other affected parties.
Distinguish roles from personas
A professional title tells you part of the story. Experience, setting, case volume, access to support, business acumen and familiarity with the therapy can change the work considerably.
An experienced specialist in a well-supported center may encounter different difficulties from a clinician who sees the condition infrequently or works in a rural area. A nurse coordinating a dedicated service may have options unavailable to someone balancing that responsibility with other duties.
Develop personas around these differences. Examine confidence in interpreting evidence, decision authority, available time, training needs and exposure to clinical or organizational risk.
Use research to test the distinctions. Personas should explain variations in behavior and requirements. They should help the team understand why an approach that works in one setting may fail to support another.
Map the journey from first awareness to continuing care
The professional’s journey may begin with awareness of an unmet clinical need or information about a potential solution. It continues through evaluating evidence, discussing alternatives and deciding whether the therapy belongs in their practice.
Adoption can involve local approvals, purchasing, training, changes to referral patterns and coordination with other teams. Clinical use then includes preparation, treatment, documentation, handover and follow-up.
Map these activities without assuming a single linear sequence. Professionals may return to evidence review after a difficult case or revise their approach when colleagues raise concerns.
Distinguish the journey of adopting the therapy from the recurring journey of delivering it to each patient. Both matter, but the barriers and improvement measures can differ.
Capture decisions and dependencies
At each stage, ask what the professional is trying to accomplish and what must be available before the work can proceed.
A decision may depend on diagnostic results, a complete patient history, clear eligibility criteria or advice from another specialty. A procedure may depend on staff, equipment and an appropriate location. Follow-up may depend on information that must be captured earlier.
Show the handovers between roles, including who supplies information and who receives it. Record where uncertainty is resolved and where work is repeated.
This reveals how a product can add burden beyond its immediate interaction. A useful output may still consume scarce clinical time if the professional must retrieve, interpret, reformat and document it through separate systems.
Measure the work and the waiting
The time required for a clinical activity can differ greatly from the time a patient waits to receive it. Both belong on the map.
Measure preparation, clinical work, documentation and recovery from problems where relevant. Record queues, appointment delays and time lost waiting for missing information.
Distinguish professional effort from elapsed time. Some delays consume little active attention but prevent patients progressing. Others require repeated chasing, rescheduling or explanation, drawing capacity away from care.
Define a common unit of work so comparisons remain meaningful. Cases with different complexity may require different analysis. Averages alone can hide the patients or professionals who face the greatest difficulty.
The purpose is to understand usable capacity and patient progress in the actual working environment.
Find the capacity that governs patient flow
A pathway may depend on a small amount of specialist attention surrounded by many competing demands. Headcount alone will not show how much of that attention is available.
Examine what professionals spend their time on, including avoidable administration, repeated assessments and interruptions. Determine whether the relevant constraint is clinical expertise, supporting staff, diagnostic access, equipment or a policy governing work.
The Theory of Constraints helps focus improvement on the factor limiting the whole pathway. Increasing referrals to a service already unable to process them can lengthen waiting without increasing treatment.
Investigate the apparent bottleneck before choosing a response. Better preparation or coordination may release capacity. In other cases, additional resources or changes to the operating model will be necessary.
“The measure of a design improvement is its effect on clinical work and patient progress, including the work it creates elsewhere.”
Observe clinical work at the Gemba
The Gemba is where the work actually happens. Direct observation helps teams understand how professionals use information, equipment and judgment under real conditions.
Observe preparation, interruptions, handovers and the work following the visible procedure. Ask what the professional expected to receive and what they had to obtain independently. Capture workarounds and job “cheat sheets” that are homemade to make working with your solution easier.
Workarounds deserve particular attention. A clinician may keep a private checklist because the formal process omits an important step. A coordinator may repeatedly contact another service because information arrives inconsistently.
These practices reveal requirements that interviews alone may miss. Discuss observations with the people involved so the team does not mistake an isolated event for a routine pattern. Include different settings and experience levels in the research.
Build the baseline from several sources
Gather organizational knowledge and assess technology and business perspectives before moving toward a solution. Apply that discipline to the professional journey.
Use existing clinical insight, training questions, support records and prior implementation experience to draft the map. Identify assumptions and gaps.
Assess the technologies already supporting the work. Consider compatibility with the environment, availability, maintenance, reliability and the practical resources needed for use.
Clarify the business conditions surrounding adoption. Purchasing arrangements, competing initiatives, staffing decisions and local policies may determine whether a clinically attractive solution can be implemented.
This baseline makes research more focused. It also prevents the development team from proposing changes that depend on unavailable capability or unacknowledged commitments from others.
Involve the people who can enable change
Voice of Business research asks leaders about desired outcomes, frustrations, risks and obstacles. It also identifies decision makers and influencers who should participate early.
For a healthcare professional pathway, this means understanding who can authorize changes to responsibilities, processes, resources and technology.
Ask which other initiatives could affect implementation. Identify the independent reviewers who can challenge the team’s assumptions. Agree what success will look like from the perspective of clinical work and patient outcomes.
Make the findings visible to the team members and relevant leaders. A professional may welcome a new approach while lacking the authority to secure the resources it requires. The project needs a realistic route from individual support to organizational adoption.
Use FOCUS to improve the journey
Apply the five-step FOCUS process to the evidence gathered through mapping.
Find the constraint. Identify the activity or resource currently governing the flow of suitable patients through care.
Optimize for it. Protect scarce capacity from incomplete information, unnecessary preparation, avoidable interruptions and repeat work.
Collaborate around it. Coordinate upstream and downstream roles so patients, information and resources arrive when needed.
Uplift it. Add capability or change responsibilities, processes and technology when existing capacity cannot meet the need.
Start Again. Review the pathway after improvement and identify its new limiting factor.
Automation can help when the task is understood and the proposed change supports clinical work. Evaluate its consequences, including review effort, exception handling and any burden transferred to another professional.
Turn the map into a shared improvement plan
The map should lead to a manageable set of changes with clear owners and measures. Test those changes in relevant settings and examine their effect on both professional effort and patient progress.
A Value Management Office can connect the initiatives with priorities, resources and project decisions. Clinical teams and other participants must remain involved in judging whether the changes improve work in practice.
“An effective professional journey supports a clinician through the complete job, from readiness to follow-up.”
What comes next
Use the healthcare professional journey to examine one priority pathway. Can your team explain who performs the work, where capacity is lost and what currently limits patient progress?
Build the map with the professionals involved. Establish the baseline, test an improvement at the constraint and review the result. Patient Centered Design advances when the solution and the surrounding system make beneficial care easier to deliver reliably.
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