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Managing accounting’s relevance

David Hodes, Founder

Eli Goldratt famously said, ‘Tell me how you measure me, and I will tell you how I will behave. If you measure me in an illogical way… do not complain about illogical behaviour.’ If you measure and reward activity, then activity’s what you’ll get.

This is part 2 in a series. Read the other part here: Six Questions for Financial Performance

[ Listen to the audio version, read by David Hodes]

How tempting it is to make everyone busy with production. In our traditional accounting systems, we book all this activity to profits. Credit operating expense as you debit inventory (whether work in process or finished goods), and voilà, by the magic of generally accepted accounting principles, those operating expenses are now counted as an asset on the balance sheet. In other words, you’ve made a profit without adding a dollar of revenue. The chickens come home to roost when you have warehouses full of inventory that no one wants to buy, and you’re compelled to mark them down to raise some cash and clear the way for a product people want to buy.

And don’t think this idea of activity-based costing applies only to manufacturing. Projects, with their system of earned value and the ever-so-popular S-curves, do the same job of ‘absorbing’ activity onto the balance sheet, as operating expense is credited from the project’s profit and loss. But rarely is a link made between the costs thus absorbed and their tenuous link to the critical path of the project, which alone determines when the business benefits start flowing.

What’s an alternative way to assess our business decisions that doesn’t depend on a reductionist framework which mistakenly assumes that the sum of the parts is the determinant of the value created by the whole? After all, that reductionist assumption informs the accounting methods that use activity-based costing as their guiding light.

Let’s recall the words of Charles Horngren, Professor of Accounting at Stanford University, who declared: ‘Relevant information is the predicted future costs and revenues that will differ among alternative actions. The existence of a limiting factor changes the basic assumptions underlying the cost and revenue opportunity of a particular action.’ In simpler terms, he wrote: ‘A company will profit maximise when it sells the product or service with the highest contribution per unit of the scarce resource.’

“In all that complexity was the inherent simplicity of Newton’s laws of motion”

Underpinning Goldratt’s many achievements and insights is the idea that, even in the most complex of environments, there is always an inherent simplicity. I recall him regaling an audience on his only visit to my Sydney hometown with the story of how we view the cosmos. He pointed heavenward and talked of the infinite complexity of the expanding universe: the galaxies, the stars, the planets, the moons, and the swirl of gases. And in all that complexity was the inherent simplicity of Newton’s laws of motion. Using them, we could predict to a reasonable degree where which celestial body was now and where it would be in the future. We didn’t need Einstein or Bohr to approach a more fundamental truth, as what Newton provided us was sufficiently valuable to send man to the moon and back. Physicist that he was, he took this basic idea of inherent simplicity and applied it to the world of work management.

The idea of inherent simplicity is captured in the diagrams below. If we break our system into some assemblage of parts, then the sum of the parts is not equivalent to the whole. Each part on the right-hand side of the diagram, measured by its ability to optimise its production, would inevitably lead to the generation of silos, mis-synchronisation, and departmental conflicts.

On the other hand, if we look at the system view on the left, we can see that if we want to create a leveraged systemic effect, we need only pay attention to the orange sphere, as it is either directly or indirectly connected to every other sphere in the system. A slight improvement there could be a significant gain when measured against overall system performance.

Both Horngren and Goldratt are talking about the fundamental difference between making an improvement at the constraint or doing it anywhere else. How does this idea help us to answer the Six Questions for Financial Performance?

1. Is the overall business profitable?

We know that we can measure profitability using the idea of return on investment, or ROI. In the world of constraint accounting, we measure ROI according to the formula.

Where:

T = Throughput defined as sales less variable costs
OE = Operating Expense usually made up of labour and overheads
I = Investment

The great benefit of using this means of determining profitability is that it can be used from the board room’s global decisions to the work supervisors’ local decisions. And it can be applied to horizons from short to medium to long.

In most cases I’ve encountered, sometimes with more effort than others, this formula can even be applied to decision-making on the shop floor. Should I work on this breakdown or that? Well, which one is likely to have the most significant impact on T, OE, and I? Indeed, any decision we make should have the calculation of ΔT, ΔOE and ΔI, where Δ is the change in the value of the variable that arises as a result of any given decision.

It also makes sense to track the trends of T, OE and I over the last five years and see if T is growing faster than OE over the longer haul. Useful ratios are T:OE, which measures how much throughput is generated for every dollar of operating expense incurred. Anything less than 1, and you’re losing money. T:I is a useful idea for capital productivity—that is, how much throughput is generated for every dollar invested. Both of these ratios should also be plotted over the previous five years to see if you are getting better at generating cash, and forecast for the next five to understand the impact of any investments you might make.

2. Is a given strategic business unit within the overall business profitable?

When we look at the profitability of a given business unit, we must be sure to understand which costs and revenues are strictly associated with that business unit and which are part of the funny money that arises from transfer pricing and cost allocation decisions. In other words, we need to know what happens to T, OE and I at the parent company level if we are to assess the subsidiary business unit properly. We must know the business unit constraint and whether it’s in supply, make or the market. We must understand what cash flows (investments, revenues, margins and costs) the business can generate in the short, medium and long term.

And then, even if the answer to all of these questions comes up in the positive, we must not forget to question the opportunity cost of focusing the ultimate constraint of management attention on this business unit versus the other opportunities available to the parent business.

3. Is a given product or service attractive for us to make and sell?

Once we understand where our constraint is, we can use Horngren’s formula for profit maximisation to establish which of our products or services delivers the most bang-per-buck per unit of the constraint. We call this bang-per-buck ‘product octane’. The chart below shows a plot of a range of products, all of which require the use of the constrained engineering resource. The x-axis shows how much throughput that product will deliver over a year; the y-axis measures the octane—that is, how much scarce resource the product consumes. The blue lines represent the average octane and throughput per annum for all products.

Quadrant one products should be high on the agenda for sales promotion, as they yield a high throughput for every engineering day. There is also the chance to establish elasticity of demand—that is, what happens if you have a slight drop in price that doesn’t affect octane too much?

Quadrant two products are the star performers, and you should always look to be selling more of these. If you can’t further penetrate existing markets, then go out and look for new segments or territories.

Quadrant three represents those products that deliver low sales while overusing the scarce resource (engineering in this case). They should be dropped from the range of products or perhaps outsourced so that they don’t use precious constrained engineering time.

Quadrant four represents solid performers in annual throughput contribution. However, it would be even better if they could be moved into quadrant two by relooking at their design such that they spend less time in engineering.

A similar idea to product or service octane applies to project octane when selecting the portfolio of projects you undertake in any given horizon.

4. Is a given customer or customer segment attractive for us to do business with?

If your constraint is in the marketplace, that is, you cannot get enough customers to buy the capacity you have for generating products and services, you at least need to know if servicing a given customer is profitable. That is, the throughput generated by their sales exceeds the operating costs that would go away if you stopped servicing them.

If your constraint is in make or supply, you could view your customer portfolio through the lens of the octane grid and assess where each customer lands in terms of octane and throughput against the same metric for the next best customer. Rather than saying no to the marginal customer, using them to test your assumptions about pricing is often worthwhile. A price increase could improve octane and make them more attractive than the next best option.

5. Should we make the product or service ourselves or buy it from a third party?

Using the ΔT, ΔOE and ΔI framework gives you a robust way of testing whether a product should be outsourced. As mentioned above, a low octane, low throughput product could be a good candidate for outsourcing if it makes way for more productive use of the capacity it yields. However, if the constraint is in the market, you need to test what the actual impact will be on T, OE and I through the decision to outsource. Proper analysis may indicate it’s better to invest in additional capacity than to outsource production because of the impact on lead times, delivery reliability and the negligible impact it may have on the remaining operating expense.

6.Should we make a given investment?

Investments are usually made as part of the Uplift step of the 5-Step FOCUS. It’s relatively simple to assess if an investment is required due to an existing or anticipated constraint. Notwithstanding the inherent risk associated with any investments, assuming you have done your homework on your assumptions, you can apply the TOEI framework to your decision-making. For any given investment, so long as the uplift in risk-adjusted throughput is sufficiently positive relative to any increase in operating expense, there will be a nett benefit in terms of ROI. Which, after all, is what we’re in business to do.

Read Part One: Six Questions for Financial Performance

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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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The healthcare professional: the hidden constraint in patient flow

Ensemble Administrator

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.”

Healthcare professionals govern critical transitions

A medical device patient journey commonly depends on several healthcare professionals:

  • A primary care professional recognizes a problem or makes a referral.
  • A specialist assesses the patient and manages the disease pathway.
  • Diagnostic professionals generate and interpret evidence.
  • A managing physician supports authorization or reimbursement.
  • An interventional specialist confirms eligibility and performs a procedure.
  • Nurses, educators or allied health professionals help the patient adapt.
  • Follow-up teams monitor efficacy and coordinate adjustments.

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.

The HCP works within a system

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:

  • Requires information that is hard to obtain
  • Interrupts established clinical workflows
  • Produces outputs that are difficult to interpret
  • Adds documentation without removing other work
  • Fails to connect with existing systems
  • Demands training that cannot be sustained
  • Transfers work or risk to another professional
  • Provides a result without clarifying the next action

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?”

Identify the real healthcare professional personas

“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:

  • Clinical responsibility and decision authority
  • Frequency of encountering the condition
  • Experience with the procedure or technology
  • Access to information and specialist support
  • Available time
  • Confidence in interpreting results
  • Responsibility for follow-up
  • Exposure to clinical, legal or financial risk

These personas clarify who performs each job and what support each person requires.

Map the HCP journey

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:

  • What is the HCP trying to accomplish?
  • What information is required?
  • Where does the information come from?
  • What decision must be made?
  • What could cause delay or rework?
  • Who depends on this action?
  • What must happen before the patient can progress?

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.

Find the HCP constraint

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.

Go to the clinical Gemba

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:

  • How the HCP prepares
  • Which tools and information sources are used
  • What interrupts the work
  • Where the HCP waits or repeats activity
  • How uncertainty is communicated
  • What must be documented
  • How work passes to the next person
  • How the HCP recognizes that the job is complete

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.”

Define the HCP’s job to be done

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:

  1. Define the intended clinical outcome.
  2. Locate the necessary information and resources.
  3. Prepare the patient, equipment and environment.
  4. Confirm readiness and choose between alternatives.
  5. Execute the clinical activity.
  6. Monitor its progress and results.
  7. Modify the approach when circumstances change.
  8. Conclude, document and prepare for subsequent care.

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.

Convert experience into measurable outcomes

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.”

Apply FOCUS to HCP capacity

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.

Connect HCP evidence with enterprise execution

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:

  • Which HCP groups influence the pathway
  • What each group is trying to accomplish
  • How the work happens in practice
  • Which outcomes remain poorly served
  • Where HCP capacity constrains patient flow
  • How the proposed solution changes the wider care system
  • How improvement will be measured

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.


What’s next?

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.

READ MORE

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Patient flow: the missing system in Patient Centered Design

Ensemble Administrator

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.”

The patient journey is a flow system

A typical medical device journey may include:

  1. The patient becomes aware of a possible therapy.
  2. A primary care professional or specialist assesses the patient.
  3. Diagnostic work determines whether the therapy is appropriate.
  4. The patient secures authorization or reimbursement.
  5. An interventional specialist confirms and plans the procedure.
  6. The patient receives the device or therapy.
  7. The patient learns how to live with the solution.
  8. Follow-up identifies any necessary adjustments.
  9. Periodic reviews monitor longer-term efficacy.

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.

Processing time tells only part of the story

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:

  • How long does each activity take?
  • How long do patients wait between activities?
  • How many suitable patients enter each stage?
  • How many progress to the next stage?
  • Where and why do patients leave the pathway?
  • How much total time passes before the patient receives the solution?

The answers reveal the true performance of the patient system.

Find the constraint

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?”

Understand why patients remain in or leave the flow

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:

  • The importance the person gives their health
  • Their confidence in dealing with healthcare professionals
  • Whether they act independently or need encouragement
  • Their comfort with technology
  • The pressures of work, family and daily life
  • Their ability to understand and act on clinical information
  • Their willingness and ability to pay
  • The outcomes they most want to achieve

These differences affect whether patients enter the pathway, remain engaged and successfully adopt the solution.

Go to the patient’s Gemba

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.

Understand the patient’s job to be done

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:

  1. Define what must be achieved.
  2. Locate the required information and resources.
  3. Prepare for the activity.
  4. Confirm readiness and choose between alternatives.
  5. Execute the activity.
  6. Monitor whether it is working.
  7. Modify the approach when circumstances change.
  8. Conclude or prepare for what follows.

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.

Turn patient experiences into evidence

Stories create understanding, but investment decisions require structured evidence.

Patient observations and comments should be converted into outcome statements that identify:

  • The desired direction of improvement
  • A measure of success
  • The object being controlled
  • The circumstances in which it matters

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.”

Apply the five-step FOCUS process

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 Centered Design is an operating system

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:

  • Which patients it intends to serve
  • What those patients are trying to accomplish
  • How the complete patient pathway operates
  • Where patients wait or leave the flow
  • Which outcomes remain poorly served
  • What currently constrains successful patient access
  • How the proposed solution improves the whole system

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.


What’s next?

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.

READ MORE

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