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Of all life’s gifts, time is the most precious. None of us escapes its clutches. As every minute ticks by, our quota is relentlessly reduced by that minute, then the next and the next. Prioritising how we spend our allotted time is one of our most consequential challenges.
[ Listen to audio version, read by David Hodes]
This is part 5 of the series. For more on this, see Part 1 | Part 2 | Part 3 | Part 4
Since most of us spend most of our non-sleeping time at work, let’s focus on the work arena and see how we might make a difference there. If we are to make a meaningful contribution to our organisations, either before we retire, or once it’s our turn to ‘hop the twig’, we clearly have to sift the important from the urgent and then act on those areas of highest leverage.
But how do we know what’s most important? How do we come to grips with what’s important today, and how that changes day to day, week to week and on into the longer horizons?
“Before even taking the first step to plan the work,
we must establish our goal”
If we are going to act by priority, it is essential that we have an understanding of the system as a whole, that system being the organisation within which we do our work. Let us restrict ourselves to thinking about a business, and understand that we generally organise work into strategic business units, and then into portfolios, programmes, projects, workplans and all the way down to tasks.
Those tasks, which are at the lowest level of the work breakdown structure, are how we give explicit instructions to specific people to fulfil a business requirement. The task or quantum packet of work may be part of a project or, equally, could be derived from the week’s production schedule. The tasks may be routine, such as participating in a regular meeting, or could be ad hoc when attending to something broken.
At every level of the business, then, we need to be aware of the two components of managing work—that is, planning and execution. Before even taking the first step to plan the work, we must establish our goal. At least how much of what by no later than when would be a good start. And since we are talking about a business, it will be framed in terms that everyone is familiar with—that is, to provide the shareholders with a sustainable and competitive return on investment. Setting this goal has to be priority number one, because if you don’t know where you’re going, anywhere will do. Establishing a realistic but achievable goal has the effect of aligning people and encourages them to think about what critical success factors will lead to its achievement.
Next comes the issue of how you are going to measure success. If the goal is to deliver a sustainable competitive return on investment, then you need to know how much profit you’re expected to generate and how much capital you’ll need to invest in getting you there. To deliver a healthy profit, clearly the bigger the margin between sales and costs, the better. And, to keep investment to a minimum, you want to minimise work in process by accelerating speed to market.
Now, we’re all set. We know what our system is, we have established a goal, and we’ve got ourselves some critical measures to track how we’re going relative to that goal. Then we encounter the laws of physics in the form of constraints. We can’t do everything; and, indeed, neither can we do all that we have chosen to do all at once. We have to prioritise. But how do we decide how to go about the process of prioritisation? What means can we use that will apply equally at the level of the business as it does through the whole chain of the work breakdown structure—from the portfolios through the programs, projects, workplans and tasks?
“The laws of physics make the idea
of limiting factors incontestable”
Theory of Constraints (TOC) is quite simple. It says that for all systems, the rate at which we create value is governed by very few limiting factors. Often, just one. If our system had no constraints at all, we would have a magical machine that could produce infinite widgets instantly. We would complete our projects’ critical paths in no time, manufacture our replenishment items in an instant and fulfil every request at the moment it’s made. The laws of physics make the idea of limiting factors incontestable. But, it’s easy to lose sight of what it means in reality. Often, a single constraint severely limits the throughput of a system. Prioritising work on the constraint is therefore of the essence when in pursuit of a high-performance result.
There’s another profound—and counterintuitive—consequence that few consider. If we agree there is a constraint, then those people or machines that are not the constraint will, by definition, have capacity to spare. When you know where the constraint is at any given moment, you also see where you have reserve capacity. We should make every effort to deploy non-constrained resources in a systemic and systematic way to focus on supporting and collaborating with the prime resource assigned to work on the rate-determining activity.
Let’s take a simple example. Say there are two tasks to complete on a project, and one of them is on the critical path. The other has some slack. The one on the critical path could go faster if the person working on the one with the slack helped out. Thus, prioritising the work of the latter to help out the former is being systemically responsive to resource constraints. It may be the case that the latter’s KPIs are in jeopardy, but the prioritisation measure has to be to do what is best for the organisation as a whole. Or, as Deming put it, ‘The object of any component is to contribute its best to the system, not to maximise its own production […] Some components may operate at a loss themselves in order to optimise the whole system.’
As a prioritisation mechanism, there is a simple brilliance to the 5-Step FOCUS process used in the practice of the Theory of Constraints:
1. Find the constraint
2. Optimise it
3. Collaborate around the optimisation decision
4. Uplift the constraint
5. Start again
So let’s see if it can help us at all levels of the work breakdown structure. First up is the portfolio of work for the strategic business unit. However we select the work comprising the enterprise portfolio, it will make a demand on the human, material, information and financial resources of the business.
But what will the return be? Typically that is measured by looking at the NPV (net present value) of all future cash flows associated with each project in the portfolio. This method, on its own, is a poor way of prioritising, as it takes no heed of that fundamental of systems thinking—the existence of a constraint.
A much better means of prioritisation is to understand the portfolio constraint—that is, the resource with the highest ratio of load to capacity—then calculate the project octane of every project using this critically constrained resource. The project octane is a measure of how much throughput we generate per unit used of the critically constrained resource used.
If this prioritisation of the pipeline doesn’t deliver the desired organisational goal, then you can readily calculate how much more resource of which type do we need for how long to open the project pipeline sufficiently to deliver the requisite throughput. Applying a constraints-based approach to portfolio selection and prioritisation is the first big step to exceeding what you would otherwise think of as being reasonable and possible. It also sets up the programs of work in the right relationship with each other.
But, what about down at the project level? Well, we all know that the critical path determines the time it takes to complete a project. The longest chain of events from beginning to end. Or is it? Well, not quite. We have to once again take into account whether or not there are any resource constraints. If you’re in the happy position that you can get as many of whatever you need as the plan calls for, then the critical chain equals the critical path.
However, if we extend the lead time of the project by virtue of having to resolve contention for critically constrained resources, then we have a critical chain—a resource-levelled critical path. Through some intelligent management of task variation, we actually define the critical chain as the longest chain of events calculated at the average touch time for a task (eliminating any waiting time) with an aggregated buffer added to the longest chain, equal in time to half as long as that longest chain. Some workstreams feeding into the critical chain can have their own buffers.
What does this have to do with prioritisation? Well, in execution, we monitor not only the rate at which we complete the work on the chain but also the rate at which we consume the buffer. The relationship between the percentage completion of each at any given time is called the critical ratio, and it gives us a clear prioritisation signal for the number-one task. If by virtue of Murphy, a feeding chain has become longer than the critical chain, then that chain assumes the mantle of ‘penetrating chain’. Whether critical or penetrating chain, we can identify rapidly and unambiguously as the priority, the first task in the sequence which makes up the chain.
Production systems, through the use of Drum Buffer Rope (DBR), similarly uses the 5-Step FOCUS to produce a ‘drum’ schedule and execute against that schedule. Buffers are used in a similar way to Critical Chain to create a prioritisation signal. We divide the time between the release of raw materials and the production step on the drum into three zones—green, orange and red. We can keep track of whether or not a task is fully-kitted as it moves towards its targeted time at the drum. If we haven’t fully kitted, we have a means of creating a valid priority signal to the expediting team as to where to focus their efforts.
TOC provides a valid and scaleable answer to the question of how to work by priority, whether the prioritisation question concerns the daily assignment of the humble task or the strategic allocation of resources to the organisational portfolio. Along with the other four commandments of high-performance execution, the application of TOC can create the difference between failure and success—or between the ordinary and the remarkable.
Making mastery of TOC a priority of yours appears to me to be a sensible way to spend at least some of that limited time you have left.
This article is part of our series: Five commandments for high-performance execution
Part 1: Maintain True Data
Part 2: Work Fully Kitted
Part 3: Control Work Release
Part 4: Resolve Issues Rapidly
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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:

[Background image: Hourglass on log, Sahin Sezer Dincer 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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