In this series, I share some books that have inspired me recently using the ‘book review’ format as a springboard into a wider conversation about the world of work—and how to do it better.
A Beautiful Constraint by Adam Morgan & Mark Barden
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I’ve been studying constraints and consulting in them for the last twenty years so was eager to see what I might learn from the authors, a pair of marketing consultants whose firm, Eat Big Fish, specialises in breakthrough strategies. My own background in industrial engineering and Goldratt’s Theory of Constraints gives me a very rich, but quite precise, understanding of what is meant by the oft-used ‘constraint’ word. I found the authors’ take on constraints to be highly relevant and reaffirmation that ‘the obstacle is the way’ to deep innovation.

The book articulates an impressively clear methodology for defining the constraint challenge then resourcefully planning for and implementing a solution. It all starts by adopting what they call the ‘transformer’ mindset rather than the ‘neutraliser’ mindset. This means befriending constraints and asking what they call a ‘propelling question’, which revolves around how to ‘achieve an ambitious vision without the resources usually thought of as being necessary to achieve it’. In their definition, a propelling question ‘has both a bold ambition and a significant constraint linked together’:
It is called a propelling question because the presence of those two elements together in the same question does not allow it to be answered in the way we have answered previous questions; it propels us off the path on which we have become dependent.
It’s our nature to stick with what has worked before, even when we know deep down, as leadership coach Marshall Goldsmith puts it, ‘what got us here won’t take us there’. Overcoming our adherence to a path is a key step. As a metaphor ‘break path dependence’ is stronger than the hackneyed ‘think outside the box’ as it requires you to consider the rails along which your thinking—and operations—currently run, then actively challenge yourself or your team by formulating a problem that can’t possibly be solved with today’s way of working.
‘Can if…’ not ‘can’t because…’
A powerful part of the beautiful constraint method is to develop ‘can-if’ thinking. In most difficult situations, people will respond to a significant challenge by saying ‘we can’t because…’ followed by all the obstacles that prevent any real action. Thinking of all the ways an innovative idea will never get off the ground sucks all the energy from the room. The beautiful constraint, however, flips the objection to ‘we can if…’, building momentum around creative solutions.
Chapter Four presents nine ‘can-ifs’ that lead to new thinking. Each is a ‘launch pad’ grouped around a concept such as mixing together two existing capacities, substituting X for Y, or using your customers to do the work. One example of the latter is Duolingo which is translating the web into numerous languages by assigning real webpages as homework examples for its language students. This can-if map is a great tool to use with large groups. The authors stress the need to ‘prime’ participants first to think in positive terms of overcoming challenges. They also reinforce the need to make any contributions using the ‘can if’ formulation, thus forcing ‘everyone involved in the conversation to take responsibility for finding answers, rather than identifying barriers’.
Language is important here. Even my own natural inclination is to say, ‘We could if…’, but ‘could if’ is mentally conditional (‘we could but it’s unlikely…’). ‘Can if’, however, represents a necessary condition. Each ‘can if’ statement ‘propels’ you or your participants closer to your ultimate goal. What’s more, I’ve found that gathering all your ‘can ifs’ under a goal tree you’ll be well on your way to designing a plan that leads to you achieving your organisation’s goal.
Are you building the right car?
While Chapter Four is easily worth the book’s price on its own, the text is also rich in implementation guides and stuffed with real-life stories that exemplify the author’s points. One memorable story concerns the 2006 Le Mans race and the Audi team. ‘The obvious question,’ they write, ‘for a team working to develop a new race car would have been:
“How do we build a faster car?” But Audi is a company that has at its heart being progressive, and so instead of asking his team the obvious question, the Chief Engineer asked a more progressive one: “How could we win Le Mans if our car could go no faster than anyone else’s?” A bold ambition with a significant constraint, plus a propelling question, took them to put diesel technology into their race cars for the first time. For the answer was fuel efficiency: they could win Le Mans with a car that wasn’t faster than any of the other cars, if it took fewer pit stops. And they were right: the R10 TDI placed first at Le Mans for the next three years.’
Naturally, this story appealed to the engineer in me. But this kind of thinking is exactly what I aim to apply to the challenges my clients present. We have to strip away our preconceptions to get to the heart of the problem. What’s the real goal? Is it to make a faster car? Or to win the race? How would that apply to your own situation?
Besides its content, another impressive aspect of the book is the authors’ obvious understanding of the importance of presentation when introducing new ideas. The excellent organisation of information—with clear nutshell intros, highlights, sidebars and chapter summaries—makes it easy not only to absorb the points but to retain and refer back to them later.
Make a virtue out of necessity
Morgan and Barden even make a virtue out of a production constraint of the book itself. In my memory, the book was ‘full colour’. Yet in returning to it to prepare this article, I found it used black and white photography throughout. What had created the impression of full colour? A simple, clever, colourful typographic jacket cover and the focused use of red detailing for key headers and tabs that provided easy way-finding. Along with the unusual square format, it all adds up to a book that feels energetic, fresh and modern. The whole presentation reminded me of the importance of great design and aesthetics in influencing people.
On a recent client engagement—inspired in part by A Beautiful Constraint—we went the extra mile by designing a visual and verbal framework that represented the critical success factors for a core function of our client’s organisation. The effort was praised by attendees at the team-leaders’ workshop and really helped cement the ideas they would need to convey to their teams. A few months later, we were happy to see the design concept had been appropriated by the CEO to highlight critical success factors for the organisation as a whole.
The kernel of what we do at Ensemble is to apply the Theory of Constraints to business challenges. Yet although the late Eli Goldratt broke new ground with his ‘business novels’, such as The Goal, the community that carries on his work often assumes everyone will just fall over themselves to understand its sometimes abstruse terminology. We are trying to make it more accessible ourselves with, for example, the 5-Step FOCUS. Morgan and Barden provide further inspiration for how to compellingly communicate new ideas.
One final quote from A Beautiful Constraint to leave you with:
‘If we don’t ask propelling questions of ourselves, someone is going to ask them of us, and by that time we will be behind the curve.’
As almost every industry faces disruption on a new and urgent scale, it’s worth forcing yourself to consider radical alternatives to the way you currently do things. I highly recommend A Beautiful Constraint to enrich your thinking about the obstacles you face. More often than not, constraints are not the problem, but the means through which we achieve our goals.
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What’s next?
The change from standard thinking to Theory of Constraints (TOC) is both profound and exhilarating. To make it both fun and memorable, we use a business simulation we call The Right Stuff Workshop.
We’d love to run it with you. To learn more:

[Background photo by Tony Webster on Unsplash]
‘It is the framework which changes with each new technology and not just the picture within the frame’—Marshall McLuhan
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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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We’ll only use your email address for this newsletter. No sales calls