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In my article Competing by Managing Asset Bottlenecks, I unpacked our value statement: ‘We help ambitious executives in industrial environments systemically improve production’. This article looks at four levers that fulfil this promise to make Asset Constraint Management yield its full potential. First, let’s see why it’s so essential to get the most from your assets.
[Listen to audio version, read by David Hodes]
This is Part 1 of our series on Asset constraint management: Part 1 | Part 2 | Part 3 | Part 4 | Part 5
As a species, we are generally more anxious about loss than we are moved by imagining the rewards of the pursuit of gain. Fear of failure often motivates more than the pursuit of a distant goal and will, therefore, likely trump whatever instincts there are to strive for success. We will often play not to lose rather than play to win. When the chips are down and the organisation is not performing well, the usual reaction is to shut down reason and revert to the fight or flight centres of the brain—what Daniel Kahneman called System 1 thinking in his book Thinking, Fast and Slow.
In a scenario where the competition squeezes you on price, or an increase in the cost of labour and material inputs eat into your margins—and sometimes both—the gut instinct is to cut costs. In the heat of battle, this cost-cutting is often done without much in the way of a business case validation. It will almost certainly not entail thinking through a detailed plan on how to bring the assets back to high-reliability once the crisis is over. The context within which we make these reactive decisions is often one of high anxiety and usually serves the needs of senior executives—several levels of abstraction away from operations—seeking to mollify analysts, boards and shareholders.
How many asset managers would be courageous enough to declare that the executive’s short-term gain comes at a high long-term cost to the business? In the world of asset management, you can increase the interval between major maintenance events and save significant amounts of today’s cash outlay, despite the asset being on a slide from tip-top form. The executive gets an immediate win by saving costs and then, unjustly, targets operations down the track after unplanned breakdowns lead to production losses. The asset management team cops a hit and is forced to pay nine stitches for the one not completed on time. And, inevitably, the planned maintenance work has to be done anyway. Not only have you lost production through unplanned outages, but all you have done in terms of saving the cost of the major maintenance event is kicked the can down the road.
“Fear of failure often motivates more than the pursuit of a distant goal”
There is a further effect of this rush to cut costs. In most cases, the people charged with analysing where and how to cut costs are pulled away from the regular rhythms and routines of running their part of the business. You add workload to an already busy schedule as you redo budgets, compute the forecasts and keep going back to get to a number to appease the powers that be. There is little heed paid to the load put on these analysts and the resultant stress that arises. They know they are mortgaging the future of staff engagement and equipment performance in pursuit of solutions which will likely result in only a short-term fix to a current cost problem. It diminishes pride in work and builds a culture of cynical compliance. Although the easy way out usually leads back in, we are seldom bold enough to call a halt to the madness.
What is the way out of this bind? What can we do to sustainably break the cycle of kneejerk responses to the inevitable ups and downs of the market? It is not enough to issue pleas to the workforce to freeze recruitment or make contributions via the suggestion box to cost-saving ideas. The systems thinker looks for leverage, and the leverage lies in a systemic approach to improvement of production, as first outlined in last week’s article.
There are four major areas where we can increase production without compromising safety or increasing costs:
1. The planning and execution of projects
2. Production maximisation
3. Maintenance management
4. Contractor controls
The good news is that the Theory of Constraints (TOC) was invented to address the planning and performance of work in a consistent manner, with a single organising principle, across all of these areas of focus. Let’s take a brief look at each in their turn:
A forestry manager had a well-drilled team of axemen able to cut more cords per hour than any other. They had learned all the lessons of highly effective people such as ‘sharpen the saw, begin with the end in mind etc.’ When they got to the end of the project, they did a great job, very efficiently, but cut down the wrong forest.
Portfolio selection is the art of making the right decisions as to which projects you do, in what sequence, and when, based on the finite resources available to get them done. Understanding your project’s ‘octane’, or NPV per unit of your scarce resource, makes all the difference to optimising your flow of cash. Furthermore, an analysis of this sort will provide you with an accurate measure of where the focused investment of specific additional resources can yield a disproportionate outcome for the overall portfolio.
Critical Chain Project Management (CCPM) is the only method of project planning and execution which has explicit and proven means of addressing the twin challenges of being restricted to a finite resource pool and operating in environments of intrinsic uncertainty. The method includes the ability to systematically program and pipeline the execution of multiple projects based on the system’s bottleneck and hence yield an optimum result for increased volumes and reduced operating expense.
You maximise production potential by first choosing the right projects in the portfolio. Executing projects flawlessly is how you turn portfolio possibility into business reality. Having capability in the TOC project planning and execution capabilities is a path to both doing the right things, then doing them right.
Increasing volume through an existing asset base has two benefits. The obvious first one is the contribution made by the extra output. Every extra unit produced without any increase in fixed costs adds the whole of the increased throughput (marginal contribution) direct to the bottom line. Likewise, the increased output dilutes the fixed costs of the business. Thus the unit cost of production is reduced—an important measure when trying to get into the lowest quartile of the cost curve.
The TOC way to safely and reliably increase production is Drum Buffer Rope (DBR) What’s remarkable about DBR is its wide variety of applications. Once the concept is understood, you can apply it across an array of asset management fields such as synchronising maintenance work where complex interactions occur between shared resources and different areas of the plant. Or managing the high number of technical queries hitting the desk of the reliability engineers as operations look to get the most productive use of these scarce custodians of continuous improvement. You could even apply it to processing the qualifications of contractors as they mobilise for a major maintenance event.
Typically maintenance is made up of four big categories: routine maintenance, emergency work, emergent work (which you don’t need to address immediately) and shuts.
Doing the work of regular maintenance on time, in full, is a production issue and thus lends itself very well to a Drum Buffer Rope approach. It has the same characteristics as most engineering job shops. Shuts, on the other hand, are significant events which have a defined scope, cost and schedule. They are therefore best treated as projects with CCPM—especially its most recent breakthrough innovation: two-tier scheduling.
Using the constraint accounting framework provides asset managers with the means of calculating the cost of an hour gained or lost at the value chain’s bottleneck. In asset management, the gains and losses typically dwarf the associated costs. In the case of routine maintenance, it’s about delivering high levels of schedule adherence on the day; for significant maintenance events, such as shuts or checks, it’s about compressing the length of the critical chain.
By contractors, I mean anyone who does work for the organisation who is not a full-time employee. Contractors could include anything from engineering consultants to software specialists and from trade craft to project managers. One of the features of TOC is the ability to articulate both the supply and demand of resources required to achieve the work outcomes. When using its methods of project and production management, the attention to the detail of quantitative work management provides a framework and practical means of effective resource management.
Knowing what kind of resource by skill type is available for any given time and place lets us find the constraint. It also naturally corresponds to the demands of those who are accountable for contractor controls: work management, supply, finance, training, safety, and execution to name a few. Being able to integrate the plethora of information systems involved in accounting for everyone who comes to do work on site creates a real source of competitive advantage.
Schedules of rates, skills matching, timesheeting, qualification verification, rosters, inductions, vendors payments are all brought under one umbrella. We can accurately check the work required on any given day against the people we have to do it and find the magic Goldilocks number. Too many and we’re wasting money—too few, and we’re wasting time. Time is money and money is time.
An added advantage of a seamless approach to end-to-end contractor controls is the massive reduction in overhead burden in processing dozens of different spreadsheets to arrive at an accurate, fair and timely accounting of who owes what to whom for what work.
These four pillars of Asset Constraint Management lead to outcomes that would be thought neither reasonable nor possible without a systems thinking approach.
This is Part 1 of our series on Asset constraints management.
Part 1: Asset Constraints Management Capabilities
Part 2: Projecting Projects
Part 3: Producing production
Part 4: Maintaining production
Part 5: Controlling contractors
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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:
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[Background photo: American Public Power Association on Unsplash]
“Know the whole, focus on the constraint.”
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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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