The latest in our series that uses the ‘book review’ format as a springboard into a wider conversation about the world of work—and how to do it better.
Principles: Life & Work by Ray Dalio
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‘Principles,’ says Ray Dalio, founder of the world’s most successful hedge fund, ‘are ways of successfully dealing with reality to get what you want out of life.’ His stated personal goal of ‘meaningful work and meaningful relationships’ is one most of us could subscribe to, and his fundamental question is: ‘Are you willing to fight to find out what’s true?’ By the end of his book, you may wonder if you’ve been fighting hard enough.

The first part of Principles is a context-setting memoir. Dalio tells how, as a teen, he put his caddying money into some stocks and saw them triple in value almost overnight. It was dumb luck, but he was hooked. Frustrated by rote learning at high school, he thrived at the local college and later attended Harvard Business School. After a stint as a commodities trader at Merrill Lynch, he started his own investment firm and had great success before spectacularly backing the wrong horse during the Latin American debt crisis of the late 1970s. As a self-confessed ‘arrogant’ 34-year-old, he even testified before Congress about why a bear market was on the way, before events proved him completely wrong. He had to lay off his staff and even borrow $4,000 from his father to pay his family bills.
This painful failure changed his outlook and set him on a new path. Dalio said to himself: ‘Rather than thinking “I’m right,” ask the question: “How do I know I’m right?”’ To make money as an investor, he knew he had to bet against prevailing opinion and be right. After all, as he puts it, ‘the consensus is already baked into the price’. So his quest became to find the smartest people possible who would be unafraid to disagree with him, then use their combined powers of reasoning to distinguish truth from opinion and conjecture. His rise, fall, and rise again is the story of Bridgewater Associates, the world’s largest hedge fund.
Incidentally, Dalio was also one of the few voices to anticipate the Global Financial Crisis of 2007-8 which brought Bridgewater into the spotlight. He decided to release, for free on the internet, a document he’d meticulously compiled, listing two hundred or so ‘principles’, previously only available to employees. After it was downloaded over 3 million times, he decided to expand them with even more rigour into the published version. The book’s second part is called ‘Life Principles’ and the final section is ‘Work Principles’.
The quest for truth
Dalio designed his organisation to be an ‘idea meritocracy’, or ‘let the best idea win’. It’s not an autocracy, where he would make the decisions, nor is it a democracy. When it comes to determining the principles which underlie any given situation, such as whether or not a given asset class will rise or fall, everyone gets a say. Crucially, though, not everyone’s say is equal. The views of those with a track record of success are given more weight than someone with less experience or knowledge. In fact, everyone has a ‘believability rating’—and everyone can see everyone else’s rating in a kind of ‘baseball card’ listing a lot of other attributes. It’s all about understanding ‘how other people are wired’ so they can understand their colleagues’ humanness and fallibility. And their own. Patented apps such as the Dot Collector, in which people rate everyone else in a meeting in real time, add to the firm’s mystique.
All this stems from the two necessary conditions Dalio proposed for the development of a culture that could support an idea meritocracy—radical truthfulness and radical transparency. In most organisations, these commodities are in very short supply, as is his dogged persistence in getting down to root causes. It is the human power to reason that allows us to achieve great things. Yet too often satisficing using proximate causes gets in the way of clear thinking. In tracking causation through Socratic inquiry (‘Why do you think that?’ ‘What could we assume instead?’ ‘How is this similar to another decision?’), Dalio shares much with Eli Goldratt (see my post on It’s Not Luck).
‘Triangulating your view with believable people who are willing to disagree’ is how he believes we get at the truth of a situation. And ‘thoughtful disagreement’ is something few people are able to pursue, he contends, because emotions get in the way. Dalio credits Transcendental Meditation as an aid to ‘getting above’ his own emotions. For a non-academic, he has also dived deep into neuroscience and psychology; the reading list at the book’s end offers a great survey of current thinking that any of us can learn from without a specialist background.
I was pleased to see that Bridgewater uses Elliot Jaques’ Stratified Systems Theory as one of its tools for categorising people’s capabilities, although it’s only mentioned in passing. While we tend to accept that people have different natural physical attributes, such as height, strength or hand-eye coordination, most of us instinctively shy away from the idea that people have different cognitive horsepower. Jaques, though, offers ‘modes of thinking’ that relate to an individual’s ability to handle complexity and different time horizons, collected from thousands of data points. (But more on him in a later article.)
“Those are my principles, and if you don’t
like them…well, I have others.”—Groucho Marx
Unusually for a CEO, Dalio has opened up his business to outside academic scrutiny, with case studies appearing in Adam Grant’s Originals, Robert Kegan’s An Everyone Culture and Edward Hess’s Learn or Die. All experienced the culture firsthand, sitting in on meetings in which people’s performance was criticised and the details shared to anyone curious to know.
Hess found that when he later shared Dalio’s principles in 2013 with ‘sixty-five smart, second-year MBA students’ and asked if they would like to work in a company like that, only three actually raised their hands. People who have excelled academically—always being praised and experiencing little failure along the way—seem to have a harder time accepting criticism when it comes. And it comes to everyone. In fact, employee retention is one of Dalio’s top areas of focus as he moves into a mentoring role. According to Hess, about 25% of new hires leave within 18 months. Bridgewater’s challenge is to find enough smart people who believe in radical transparency. Talk of ‘getting in sync’ can indeed make Bridgewater sound like it puts the ‘cult’ in culture. But my feeling is that such phrases are more like a shorthand, mantras that help speed things along for the people concerned.
Hess goes as far as to say that, by embracing scientific developments in learning, Dalio has furthered Peter Senge’s work set out in The Fifth Discipline (a standard text here at Ensemble), stressing Dalio’s focus on the ‘feedback loop’ and stating that ‘the rate and quality of an organization’s improvement and learning is highly dependent on how effectively and quickly it can process feedback loops’.
Pain + Reflection = Progress
In Originals, Adam Grant does challenge Dalio on having so many principles, not so much accusing him of the Groucho Marx quip as citing evidence that ‘the more principles you have, the greater the odds that employees focus on different values or interpret the same values differently’. Dalio’s response is that ‘a principle is just some type of event happening over and over again and how to deal with that event. Life consists of billions of these events, and if you can go from those billions to 250, you can make the connection, “Ah, this is one of those.”’ Dalio did agree, however, that the hierarchy of principles could be clearer; some are more important than others.
Dalio claims his principles can apply to any organisation and, indeed, to life in general. Reading the book, I was constantly caught between thinking that, on the one hand, these are great ideas while on the other questioning what it would really take to be radically truthful and transparent. I’ve always run Ensemble on the basis of open communication, for example, opening up our books and proposals to anyone in the organisation. I confess, though, that the idea of recording every significant meeting for anyone’s ears would be a challenge. Possibly so much recording actually allows some things to hide in plain sight. After all, who will take the trouble to sift through it all?
If I have a quibble with Dalio’s style it’s his propensity to imagine that every aspect of human endeavour can be reduced to an algorithm. He sees the organisation as a machine. As a systems thinker and engineer myself, I applaud his determination to understand how every element of the system interacts, but I find the metaphor overly mechanistic. In Team of Teams, Stanley McChrystal presents leadership in terms of being a gardener who prepares the soil and plants the seeds. This resonates more with my view that human beings and social systems shouldn’t be reduced to cogs in a big predictive machine. But Dalio’s storytelling belies that thought and he’s so passionate about his principles—even while inviting you to challenge his ideas with your own—that it’s easy to see past the negative connotations of the metaphor and accept the underlying message.
A final observation: although Bridgewater has been criticised by several journalists who sought out disgruntled ex-employees for stories of cultish devotion and boorish behaviour, the three leading academics in the organisational learning field mentioned above all left the firm with the highest opinions of Dalio and the ‘unique culture’ he had built. In the end, you’ll have to judge for yourself. Which is exactly what Ray Dalio would like you to do.
Questions to think about:
• Have you spent any significant time thinking about your own principles?
• Do you write down your reasons for making decisions at the time, then return to analyse them in light of the consequences?
• What would it take to introduce Radical Transparency in your organisation?
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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 by Aaron Burden on Unsplash]
‘There are three constants in life,
change, choice and principles’—Steven Covey
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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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