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Legendary management guru Peter Drucker never actually said, ‘Culture eats strategy for breakfast’. But the epigram stuck. In fact, the two are entangled; an effective strategy requires an enabling culture.
This is Part 1 | Read Part 2 | Part 3
[Listen to audio version, read by David Hodes]
But what is culture? When asked this question, many provide the tautologous answer ‘the way we do things around here’. Such a response does not help answer the critical questions of a given organisation’s culture at a given time in its history, and how a productive and generative culture might be cultivated into the manageable horizon.
Much of my understanding of culture comes from the work of Emeritus Professor Ed Schein, who founded the Centre for Organisational Learning at the MIT Sloan School of Management. Schein’s model invites us to look at three levels of culture: artefacts, espoused beliefs and values, and basic underlying assumptions.
The iceberg metaphor is helpful here in that what we see at the top, above the waterline, is the manifestation of what is going on at a much deeper level. You may walk into an office or worksite and look at the general presentation of the work environment. Is it tidy, freshly painted, filled with light, or dark and dingy? Are the spaces intentionally set out like an Apple Store, or is it all rather more like the office of an inundated cohort of junior law clerks? How do people behave towards each other? Are they competitive or collaborative? Bureaucratic or in flow? Cynical or inspired? Family-like or formal? These are artefacts. But even with these, it’s not easy to know what’s really going on, based only on simple observations of what our senses feed to the meaning-making machine of our minds.
Dig a bit deeper, and we are in the realm of espoused beliefs and values. Espoused because they are what we read on the posters, see on the presentations, and hear from the functionaries when we ask questions about ideals, goals, values, and aspirations. When we notice a discrepancy between the espoused values and the actual behaviours, we’re likely to be fed some well-rehearsed rationalisations: ‘Mary’s behaviour is not congruent with our publicly stated value of inclusion, and we have had a lot of complaints about her abrasive and demeaning management style. Still, her personal story allows us to help her more fully activate the better angels of her nature, as, despite everything else, she delivers the results the business is looking for.’
Down at the deepest level, we are into the realm of the unconscious—the same domain that informs the myths we live by. In that domain, we answer the questions about the meaning and purpose of our lives, how we got here, and what we will do with the finite time we have left. In a productive culture, there is a deep congruence of value at all the levels within which we operate: the personal, the team, the organisation, and the society in which we live.
External adaptation and internal integration
Arriving at such a state of harmony within an organisational setting is never easy. We have two significant challenges to overcome: external adaptation and internal integration. Before exploring these two challenges in more depth, it is worth quoting Schein’s definition of culture in full:
‘The culture of a group can be defined as a pattern of shared basic assumptions learned by a group as it solved its problems of external adaptation and internal integration, which has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.’
In other words, what we learn about solving the problems of external adaptation and internal integration and how we examine the assumptions that inform that learning is of the essence to culture formation.
External adaptation includes understanding how we get to play our game within the markets in which we compete. We need to articulate our mission and strategy in a way that all critical stakeholders understand. We must embrace the question that asks what the fundamental problem is that we solve for those who consume our products or services? Given our mission, what is our goal? At least how much of what, by no later than when? How must the accountability hierarchy be constructed to best serve the processes which deliver on the mission? What means will we need to secure to accomplish our mission? How is the division of human, financial, material and information resources determined and allocated? What will we measure, and how could those measures be used to control progress towards our stated goal? How will we develop a consensus on the when and what of course corrections? What are the appropriate remedial or repair strategies to be used if goals are not being met?
Internal integration proves a more challenging arena for us to understand. It begins with the idea of creating a common language, where words and conceptual categories have shared meaning. As an example, think of the number of acronyms we demand a recruit learns before they come to readily understand the local dialects. The idea of internal integration begs the question of the extent to which the integration applies. What is the boundary for inclusion, and who, then, is in or out? By what criteria is membership determined?
Once we know the group’s boundary, each must work out its pecking order, criteria, and rules for how someone gets maintains and loses power and authority. Consensus in this area is crucial to help members manage feelings of aggression. If there are no rules around the exercise of power, we trigger that primal aggressive response associated with unfair authoritarianism.
How is the game played?
Over time, every group must work out its ‘rules of the game’ for peer relationships, relationships between the sexes, and how openness and intimacy are handled in managing work. Consensus in this area is crucial to help us define trust and manage feelings of affection and love. How much damage has been done by the office affair? It’s not easy to navigate from the locker room to the board room. In brief, norms must be developed around trust, intimacy, friendship, and love.
Included in the theme of fairness at work, to develop a productive culture, we must come to share an understanding of what behaviour is heroic and what is unacceptable. Once we know these behaviours, we must achieve consensus on how we reward what is good and punish what is terrible.
And then there is the realm of the unexplainable—those events that fall outside the boundary of the day-to-day which challenges our well-worn nostrums of habit. How do we give meaning in a way in which group members can respond to them without excessive levels of anxiety?
Coming to meaningfully understand all these aspects of external adaptation and internal integration goes well beyond simply taking stock of the artefacts of culture, and even the deeper level of the espoused beliefs and values. To fully understand the culture of a group, we would need to equip ourselves with the competencies of a social anthropologist. Having said that, I have found the Competing Values framework offered by Cameron and Quinn helpful in getting an early read of the four archetypes they have in their model: Clan, Adhocracy, Hierarchy and Market. This model, illustrated in the diagram, looks at the competing values associated with an internal or external focus and whether stability and control are most essential or flexibility and discretion.
No organisation is at any given time any one of these archetypes, and there is always a natural tension between where the organisation is, compared to where the members would like it to be. There is an ongoing dynamic between the internal and external focus and whether the emphasis is on integration or differentiation. Many factors could influence the choices which value stability and control over flexibility and discretion or vice versa.
Even acknowledging that these competing values are forever in the dance of change, shifting the centre of gravity from one cultural archetype to another quadrant is far more challenging to accomplish than many in the field care to acknowledge. In the same way that a nick in a sapling is visible in the grown tree, so too does the influence of the founders run within the organisation’s DNA throughout its life.
It takes a very long time to learn to succeed in any given endeavour and the habits formed from learning how to succeed are not readily surrendered. We are far more ready to acknowledge when markets change, and our focus and comfort is found in what needs doing in the external competitiveness arena. It is far more challenging and takes much longer than we would ordinarily allow to co-create a new way of being in all the areas of internal integration outlined above.
In my next article, we’ll explore more deeply the subcultures present within most organisations as well as dig into the kinds of mental models we carry when assessing our place within a culture.
This is Part 1 of our series on Culture.
Part 1: Cultivating culture
Part 2: Culture – Digging below the surface
Part 3: The Anxieties of Changing Culture
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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.
- View the Systems Thinker Course Guide (no email required to download)
- Join us for the Systems Thinker Foundations Workshop (we run this FREE workshop once each month)
- To find out more about these, or any of our services, simply schedule a call
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[Background image: Man painting himself, Marina Montoya on Unsplash]
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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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