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.
The ONE Thing, Gary Keller with Jay Papasan
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In my last article, I quoted from the movie City Slickers in reference to how leaders should focus on what they need to do to make a transformative difference to their organisations. In some ways, that was a preview of forthcoming attractions. In this piece, I highlight some pragmatic and inspiring points from a book that will help you focus on what cowboy Curly was pointing to.
It took me some time to take up a friend’s recommendation to read The ONE Thing. Here was a book written by a hero of the real-estate market of all things, it was a best seller, and I already knew everything there was to know about focus. After all, wasn’t that the main claim of my speciality, the Theory of Constraints? And then I reminded myself of the chutzpa of Dr Eli Goldratt, who famously said he wasn’t interested in Pareto and his 80/20. He was always on the lookout for the 99/1.
Once I got over my own hubris and picked up the book, I couldn’t put it down. It’s written in a very accessible and engaging style, filled with illuminating quotes and relevant explanatory diagrams. What a treasure trove of practical wisdom the book turned out to be. Just ask the question, every day:
‘What’s the one thing you can do, such that by doing it, everything else will be easier or unnecessary?’
There are many practical tips and stories around how to achieve extraordinary results by becoming a ‘one-trick pony’, acquiring a ‘one-track mind’ and being ‘single-minded’. All this counterintuitive advice is there to help you go after what really matters and to shed the rest. I loved that they could write about the fact that when in pursuit of the one thing, everything else could get pretty messy and out of order. I also liked the way they punctured the illusion that you can have a work-life balance if you’re in pursuit of anything truly remarkable:
‘The reason we shouldn’t pursue balance is that magic never happens in the middle; magic happens at the extremes.’
It’s never balanced if you’re going to achieve great results, but they do introduce the idea of counterbalance:
‘Whatever you’re doing, be fully present. This is the secret of counter-balance: bringing our full attention to the effort at hand.’
One of the central ideas of the book is the ‘domino effect’, which the authors use to illustrate that if a chain reaction was started where every successive domino was half as big again as the one preceding it, then by the 57th iteration, what started at the size of a single domino could reach the distance to the moon. It’s harnessing this power of geometric progression that lies at the heart of the power of the one thing. Focus on what you really want and love and start with a mindset that sees you knocking over the next thing—not the ultimate prize, but just the next thing—metaphorically half as big again as the one that preceded it. And like the dominos, you’ll soon be playing in the big leagues.
There’s no such thing as a balanced life if you are going to achieve greatness.
So, what sits between you and this simple-to-understand pathway to success? Well, Keller reckons there are six lies between you and success:
1. Everything matters equally
The antidote to this is to get serious about Pareto and keep going on your to-do list until there is only the one thing left—a high leverage activity that makes all the other things on your list either go away or become much easier.
2. Multitasking
The executive function of our brains is very small relative to the rest. If you listen to your monkey mind and switch in and out of different activities, there is a huge transactional cost. Compare how much you get done when working in flow to when you are continuously interrupted.
3. A disciplined life
It’s not that we need to be disciplined across all things all the time. What we need to do is to take the 66 days required to turn a discipline into a habit so that doing the right thing becomes second nature.
4. Willpower is always on will-call
Willpower is a finite resource and should be conserved to do those things which really matter, and not spread too thin. Be aware of how much energy you have and understand that low energy correlates with low will power. So, do what matters most first thing every day, when your willpower is strongest.
5. A balanced life
There’s no such thing as a balanced life if you are going to achieve greatness. There will be times when, in pursuit of your one thing, you will forego all attention to anything else. The remedy for this is to understand the idea of counterbalance. When you inevitably have to go too far one way for a period, you must counterbalance it at other times to ensure you lead the good and fulfilling life.
6. Big is bad
Thinking that ‘thinking big’ is bad, is a bad thought. Do not be encumbered by the limiting nature of your goal, but rather set a big one and figure out what you need to do to get there. In doing so, you get to achieve your lesser goal on the way through to the bigger one. Be crazy enough to think you can change the world, as everyone who ever did was similarly crazy. Have the courage to take on your fears and use the experience of others who have made the breakthroughs as your guide. Don’t fear failure; by definition, you can’t be learning if you’re not failing.
In the section which talks about the art of a powerful question, there is a wonderful poem:
My Wage
By JB Rittenhouse
I bargained with Life for a penny,
And Life would pay no more,
However I begged at evening
When I counted my scanty store.
For Life is a just employer,
He gives you what you ask,
But once you have set the wages,
Why, you must bear the task.
I worked for a menial’s hire,
Only to learn dismayed,
That any wage I had asked of Life,
Life would have willingly paid.
More than half of a good answer is a powerful question, and it’s worth repeating the question that gives the book its title:
‘What’s the ONE thing I can do, such that by doing it, everything else will be easier or unnecessary.’
The question is posed in two parts—the big picture and the small focus. The big picture provides you with a vision worthy of your fleeting life, whilst the small focus gets you to pay attention to that one domino which starts the fall of all others. By helping you develop the powerful question through a series of concepts and exercises, Keller shows how the concept can be applied to the whole of an accomplished life, be it business, finances, family, physical health, spirituality or any other aspect of a life well lived. How to make it a habit of mind, practiced every day—full of possibility, benchmarked and routinely monitored.
In the third section of the book, he talks of extraordinary results and the relationship between productivity and purpose. I was reminded of Nietzsche’s famous dictum that if you had a powerful enough ‘why’ you could bear almost any ‘what’. Purpose informs priority, and focusing on priority delivers the productivity required to achieve your goal. And that goal, as described by the authors, is like one of those Russian dolls. It has multiple horizons to it, from the ‘someday goal’ (what’s the ONE thing I want to do some day?) through the five-year goal, the one-year goal, the monthly goal, the weekly goal, the daily goal and the right now goal: ‘Based on my daily goal, what’s the one thing I can do right now to achieve my daily goal?’ And so on back up the ladder of time.
I found the section of the book dealing with ‘time blocking’ especially useful. It just seems logical, the author’s claim, that:
‘If disproportionate results come from one activity, then you must give that one activity disproportionate time.’
How often, after all, do we ask ourselves the question as to the opportunity cost of the use of that irreplaceable and finite resource we all have, called time? What doesn’t get done in accordance with your goal if you spend time doing things which don’t advance you towards its attainment?
Toward the end of the book, Keller stopped me in my tracks with a small section called ‘Move from E to P’. The context was a piece about mastery, in which he defined the concept of mastery as:
‘The path to mastering something is the combination of not only doing the best you can do it, but also doing it the best it can be done.’
The ‘E’ referred to above is the path of the entrepreneur, which Keller argues has a ceiling of achievement and goes through four predictable phases once that ceiling is hit: disappointment, resignation, the search for greener pastures and then the repetition of that cycle. ‘P’ stands for the purposeful approach which calls on you to do what comes ‘unnaturally’. Only then can you break through the natural ceiling of accomplishment through a positive repeating cycle of focus, models, systems and breakthroughs. You can see it in the serial failed entrepreneur versus the business leader who hunkers down and learns to break through. I liken the ‘E’ and ‘P’ approach to Carol Dweck’s insights into what behaviours lead to the development of a ‘fixed’ or ‘growth’ mindset (see my review of Mindset).
Along with the six lies mentioned above, Keller talks of the four thieves of productivity:
1. The inability to say ‘No’
2. Fear of chaos
3. Poor health habits
4. Environment doesn’t support your goals
For each of these thieves, Keller has some very practical ideas as to how to start saying ‘no’, accept chaos, manage your energy and take ownership of your environment. Keller’s optimism and enthusiasm throughout are truly inspiring. As I read, I could feel myself being drawn in by his generosity and wisdom. This, I thought, is a book written by a man who lives fully in the mindset of abundance.
And, just in case you think it’s all about work, in the part on time blocking about how to organise your time to give you the opportunity to focus on the one thing, I loved the fact that they start by asking you to plan your annual calendar by considering first when and where you’re going to take your vacation. That was the first entry in my diary once I completed the book.
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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:
- download the brochure (no email required)
- schedule a call
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[Background photo by Natalia Y on Unsplash]“There is nothing as useless as doing efficiently
that which should not be done at all.”—Peter Drucker____________________________
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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