The Anxieties of Changing Culture

David Hodes

If we want positive cultural change in our organisation, we’ll need more than a simple redesign of surface artefacts. More even than challenging espoused beliefs and values. We must courageously explore the basic underlying assumptions that determine behaviour, perception, thoughts, and feelings.

Part 1: Cultivating Culture
Part 2: Digging below the surface
Part 3: The Anxieties of Changing Culture

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

Just as the nick in the sapling remains with the tree into maturity, the founder’s influence remains embedded in an organisation’s culture throughout its life. However, the way an organisation, during its founding and early growth, establishes internal coherence and adapts to its markets is unlikely to serve its midlife, maturity, decline and rejuvenation.

Ed Schein, Emeritus Professor at MIT, identified two anxieties at play when thinking about organisational change—the anxiety of learning and the anxiety of survival. Any change requires new knowledge; and, by definition, that means learning afresh. However, learning afresh means having to confess ignorance. And with that confession comes the fear that the new learning will demonstrate, at least temporarily, a level of incompetence. Along with the loss of mastery that arises as we abandon the old way in favour of the new, we experience fear that we could lose the power and status associated with our current way of doing things.

Further, what if we think we’ll be punished for our incompetence? Learning always demands a temporary fall in productivity as we gain mastery in the new ways of working. Will we be given the necessary time and instruction required to gain competence in the latest methods and tools? We also need to understand that often we wrap our identity into our jobs and the relationships they foster. Suppose the change we contemplate is structural in its nature. We might find we become so alienated from our group or the organisation at large that we either live in misery or feel compelled to leave.

“Learning always demands a temporary fall in productivity as we gain mastery in the new ways of working”

We are not automatons and are endowed by our creator with free will. Along with free will comes its flip side—free won’t—more typically called ‘resistance to change’. This is a rational response to the anxieties of learning and can take the form of denial, scapegoating or manoeuvring. When we deny, we convince ourselves that things aren’t as bad as we’re told and that the change can therefore be avoided. Scapegoating makes the case that our function or department is not the cause of underperformance and that it is others who need to change. Manoeuvring is the behaviour we adopt when we seek out special compensation for our engagement in the change. We need belaboured convincing that it’s in our interest for the change to happen, and undue persuasion that it’s in the long-term interest of the organisation at large.

So how do we overcome this real anxiety of learning and resistance to change? The big idea is to create psychological safety. In recent years, Professor Amy Edmondson of Harvard Business School has popularised the term. But it’s been around a long time. In his book, Leadership & Culture, Schein incorporates the concept in eight mutually reinforcing activities, which I quote below:

1. A compelling positive vision: The targets of change must believe that the organisation will be better off if they learn the new way of thinking and working. Such a vision must be articulated and widely held by senior management and must spell out in clear behavioural terms what ‘the new way of working’ will be. It must also be recognised that this new way of working is non-negotiable.

2. Formal training: If the new way of working requires new knowledge and skill, members must be provided with the necessary formal and informal training. For example, if the new way of working requires teamwork, then formal training on team building and maintenance must be provided. This is especially relevant in multicultural groups.

3. Involvement of the learner: If the formal training is to take hold, the learners must have a sense that they can manage their own informal learning process. Each learner will learn in a slightly different way, so it is essential to involve learners in designing their own optimal learning process. The goals of learning are non-negotiable, but the method of learning can be highly individualised.

4. Informal training of relevant ‘family’ groups, and teams: Because cultural assumptions are embedded in groups, informal training and practice must be provided to whole groups so that new norms and new assumptions can be jointly built. Learners should not feel like deviants if they decide to engage in the new learning.

5. Practice fields, coaches, and feedback: Learners cannot learn something fundamentally new if they don’t have the time, the resources, the coaching, and valid feedback on how they are doing. Practice fields are particularly important so that learners can make mistakes without disrupting the organisation.

6. Positive role models: The new way of thinking and behaving may be so different from what learners are used to that they may need to be able to see what it looks like before they can imagine themselves doing it. They must be able to see the new behaviour and attitudes in others with whom they can identify.

7. Support groups in which learning problems can be aired and discussed: Learners need to be able to talk about their frustrations and difficulties in learning with others who are experiencing similar difficulties so that they can support each other and jointly learn new ways of dealing with the difficulties.

8. Systems and structures that are consistent with the new way of thinking and working: For example, if the goal of the change program is to learn how to be more of a team player, the reward system must be group-oriented, the discipline system must punish individually aggressive selfish behaviour, and the organisational structures must make it possible to work as a team.

These activities are underpinned by his five principles, each of which should make us sit up and pay attention:

Principle 1: Survival anxiety or guilt must be greater than learning anxiety.

Principle 2: Learning anxiety must be reduced rather than increasing survival anxiety.

Principle 3: The change goal must be defined concretely in terms of the specific problem you are trying to fix, not as ‘culture change’.

Principle 4: Old cultural elements can be destroyed by eliminating the people who ‘carry’ those elements, but new cultural elements can only be learned if the new behaviour leads to success and satisfaction.

Principle 5: Cultural change is always transformative change that requires a period of unlearning that is psychologically painful.

Principle 1 tells us that, usually, learning takes place when survival anxiety exceeds learning anxiety. In other words, I will not learn if something I really value, such as my job, or position in the hierarchy, is not at stake. But, in accordance with principle 2, rather than amp up the survival anxiety, the more productive way to go is to decrease the anxiety associated with learning. For example, embody the idea that failure is a necessary condition of learning and that we should ‘fail often to succeed sooner’. Could we even go so far as to embrace our fondest memories of learning as a child and make it playful?

Principle 3 is fundamental. If we bring in the culture change consultants to tell our teams that we are embarking on an initiative to change our culture, then, after the eyes have rolled, the teams will know that the initiative is doomed. Culture doesn’t sit outside of our striving to bring greater integration to how we work together to solve the problems of adapting to our market. We need to explicitly articulate our goal and frame the initiative in terms that show how the intervention is going to get us closer to its accomplishment.

“All change requires unlearning as well as learning”

Principle 4 means we cannot be afraid to remove people who are unwilling to contribute to the learning. Notwithstanding that all should be given a fair go, the sooner these toxic elements are removed, the less the risk that their negative assessments will infuse the rest of the change team in cynical resistance to change. The effect is often salutary, as it sends a message about the mandate for change. To achieve enduring success though, the change team need to see the success from their new ways of working and reap the satisfaction that comes from doing good work well.

Principle 5 is a reminder that all change requires unlearning as well as learning. We come to understand that our mental models were flawed and that, by embracing change, the future is not going to be what we had hitherto invested so much of our energy in imagining. We need to let go of our old selves to allow the new ones to enter the arena. Thus, the first activity when creating transformative change is to create a compelling and aligning vision. For, as Nietzsche put it: ‘He who has a why to live can bear almost any how’.

To close, let’s see what Schein has to say about what a learning culture could look like:

1.Proactivity
2.Commitment to learning to learn
3.Positive assumptions about human nature (Theory Y)
4.Belief that the environment can be managed
5.Commitment to truth through pragmatism and inquiry
6.Positive orientation toward the future
7.Commitment to full and open task-relevant communication
8.Commitment to cultural diversity
9.Commitment to systemic thinking
10.Belief that cultural analysis is a valid set of lenses for understanding and improving the world.

Changing culture is not easy, but neither is it impossible. As per one of our enduring mantras, ‘to change the way you work, you have to change the way you work’. But perhaps we’ll give the final words of our exploration of culture to Deming: ‘survival is not mandatory’.

Part 1: Cultivating Culture
Part 2: Digging below the surface
Part 3: The Anxieties of Changing Culture

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What’s next?

The change to using Theory of Constraints (TOC) as an underlying operating system is both profound and exhilarating. We’ve developed the Systems Thinker Course to bring the ideas into your organisation.

View the Systems Thinker Course Guide (no email required to download)
Join us for the Systems Thinker Foundations Workshop (we run this FREE workshop once each month)
To find out more about these, or any of our services, simply schedule a call
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MedTech

Validating medical device concepts before major investment

David Hodes

Concept validation

A concept can look convincing in a presentation and still make an important task harder. A patient may misunderstand an indicator. A clinician may need information the design does not provide. A promising workflow may depend on support unavailable in the intended setting.

These problems become more expensive when the organization discovers them after committing to architecture, tooling or a launch plan.

We must ask how effectively concepts are validated before significant resources are committed. Patient Centered Design treats this as a learning discipline: turn ideas into testable solutions rapidly using low fidelity prototyping, put them in front of relevant users and gather evidence about whether they improve the outcomes that matter.

“A convincing presentation shows what the team hopes will happen. A useful test reveals what people actually do.”

Begin with a question that can change the decision

A prototype without a learning objective can generate interesting comments while leaving the key decision unresolved. Start by identifying what must be true for the concept to succeed.

Does the patient intuitively understand the required action without explanation? Can the professional recognize when the result is ready to use? Does the proposed approach fit the work surrounding the task? Will people take meaningful steps toward adoption?

State the assumption and the evidence needed to assess it. Agree what would support proceeding, what would require revision and what could make the concept unviable. Gather quantitative data along with qualitative verbal feedback.

Prioritize questions with substantial consequences for the investment. An attractive enclosure deserves less attention than an unresolved issue that could prevent safe or practical use of the whole solution.

Choose the simplest useful representation

A picture is worth a thousand words. A simple user experience prototype is worth a thousand pictures. Choose artifacts that maximize learning with the least effort. The appropriate artifact depends on what the team needs to discover.

A sketch may help users explain how they interpret a proposed interaction. A physical mock-up may expose handling difficulties. A simulated interface can support a sequence of tasks. A more complete prototype may be necessary to examine timing, feedback or combined interactions.

Build enough realism to test the assumption accurately. Excessive detail can consume resources without improving the evidence, while insufficient fidelity can conceal the issue being investigated.

Make limitations clear to participants and observers. A manually simulated function may help test an experience, but it does not establish that the technology can deliver that function reliably.

Recruit people who represent the intended use

Patients and healthcare professionals can differ in experience, confidence, physical ability, responsibilities, and access to support. Those differences influence whether the concept helps them complete the job.

Define the participants and contexts relevant to the test. Include people whose circumstances could expose difficulties the development team has overlooked.

A familiar expert may work around a confusing interface that challenges a new user. A clinician from a highly supported center may assume resources unavailable elsewhere. Research needs to reveal these dependencies.

Match the study to its purpose. Exploratory sessions can identify problems and guide iteration. They do not automatically establish population-wide performance or replace the evidence required for later design validation.

Create an Experience Café around real tasks

An Experience Café gives participants a structured opportunity to encounter concepts and talk about their experience. Its value comes from the quality of the scenario, observation and follow-up questions.

Set up situations that reflect what the person is trying to accomplish. Let participants interact with the artifact rather than rely solely on a demonstration by its designer. Build rough and rapid.

Assign roles to facilitators and observers. Agree how comments, actions and difficulties will be captured. Keep the session focused on learning rather than defending the proposed solution. Hold a conversation around the prototype. “Can you show me how you would use this?” “Tell me what you are thinking here.”

Ask participants to explain what they believe is happening and what they would do next. Observe where the concept supports that understanding and where they hesitate, improvise or seek help.

Listen without teaching away the problem

A facilitator can unintentionally make a weak concept appear successful by explaining each step or supplying missing information.

Use neutral prompts and allow participants to reveal their interpretation. When assistance is necessary, record it along with the point at which the person became stuck.

Follow observations with questions about purpose and reasoning. What did the participant expect? Which information did they look for? Why did they choose that action?

Separate a preference from evidence about task performance. “I like this one” may reflect appearance or familiarity. Successful completion, appropriate interpretation and manageable effort provide a stronger basis for assessing whether the concept addresses the need.

“Every explanation the facilitator must supply is a question about what the design expects the user to know.”

Examine the complete experience

The product interaction belongs within a wider job. Test preparation, readiness, execution, monitoring and what follows, wherever these activities affect the concept’s value.

A device may work well once configured while setup introduces avoidable complexity. A result may be easy to view while the professional still needs to transfer it manually before acting.

Include relevant dependencies on caregivers, staff, information and other systems. Investigate whether the concept reduces burden for one participant by increasing it for another.

Use realistic scenarios appropriate to the development stage. Important exceptions and recovery steps deserve attention alongside routine success. An incomplete or interrupted task can reveal weaknesses that a carefully guided demonstration leaves hidden.

Make cognitive burden visible

Ease of use involves what a person must notice, understand, remember, decide and physically do. A tidy interface can still demand substantial mental effort.

Human performance depends on limited attention, working memory and feedback. Examine how the concept supports those processes during a task.

Does it make the relevant information perceptible? Can the user understand its meaning? Is the next action clear? Can they recognize whether that action succeeded?

Look for unnecessary steps, demands to remember information across screens and alerts that interrupt without helping a decision. The best change may simplify a sequence or improve feedback rather than add another feature. Confirm its effect through observation and appropriate measures.

Measure effort alongside task success

Choose measures that reflect the priority outcome and the study’s purpose. These may include completion time, errors, requests for help, repeated actions or failure to notice important information.

Subjective workload measures can complement observed performance. NASA Task Load Index can help structure participants’ assessment of workload, while PURE provides an expert assessment of the effort required to complete tasks. Satisfaction ratings on a Likert scale can be used to compare concepts directly with each other and a baseline solution.

Do not treat one measure as a complete account of usability. Faster completion may accompany misunderstanding. A participant may complete the task correctly while reporting effort that makes repeated use impractical.

Interpret results together and examine the conditions under which they occurred. Record the limitations so decision makers understand what the test has established.

Test demand separately from technical feasibility

Pretotyping examines whether people take meaningful action toward using or adopting an idea before the full solution exists. It addresses a different question from whether a working product can be engineered.

A clearly described concept, service simulation or expression-of-interest process may provide evidence about engagement. The strength of that evidence depends on the action required and the conditions surrounding it.

A click demonstrates less commitment than a substantive implementation conversation. Neither establishes clinical efficacy or successful device use.

For medical concepts, keep representations accurate and make the test status clear. Interpret behavioral evidence alongside clinical appropriateness, access requirements and the responsibilities of the people making adoption decisions. Interest alone cannot establish that the solution should proceed unchanged, particularly when workflows in the clinical setting are involved.

Refine the value proposition with evidence

A value proposition explains which customer the concept serves, the job it supports and the difficulties it intends to reduce. It should connect directly with the outcomes identified through research.

Compare that proposition with the evidence from concept tests. Did participants experience the intended benefit? Did another difficulty become more important? Did the concept require assumptions that the intended setting cannot support? Did the concept do something better than a competitor’s current solution?

Capture both positive and negative findings. Use them to revise the concept, the proposition or the team’s understanding of the need.

Then test the important changes. Iteration should answer a question left open by the previous round. Repeating sessions without changing the artifact or research objective can accumulate comments while leaving uncertainty untouched.

Keep early findings within their proper limits

Early concept validation supports decisions about direction and investment. It does not establish all the evidence needed for a finished medical device.

Technical performance, reliability, clinical benefit and intended-use safety require appropriate subsequent work. A convincing simulated experience may depend on functions the team has not yet demonstrated.

Make these boundaries visible in the decision record. State who participated, what was tested, the conditions, findings and unresolved issues. Explain how those findings affect the next commitment.

Overall, having a “winning concept” in hand, backed by user Experience Café data along with user needs in the form of outcome statements formally structured with a direction of improvement and unit of measure, sets a development team up for success. The outcome statement user needs provide a solid foundation for the design history file.

Rapid prototype experience testing gives the team answers to key decisions and sets a target to pursue early on. This results in faster development cycles, more robust regulatory submissions, and better returns on investment spending.

A Value Management Office can connect this learning with resources and stage decisions. Testing should help the organization commit at a pace justified by evidence and concentrate effort on the uncertainties that govern progress.

“Early validation creates value when it changes the concept or the commitment before an unresolved assumption becomes expensive.”

What comes next

Examine one proposed investment. Which assumption could defeat the concept, and what is the least costly credible way to test it?

Prepare an appropriate artifact, involve representative users and observe meaningful tasks. Review the evidence, revise the concept and record the next learning decision. This gives Patient Centered Design a practical route toward solutions people can successfully use and organizations can responsibly develop.

MedTech

Developing medical device concepts around patient needs

David Hodes

A development team can become committed to a concept before it has seriously considered an alternative. The idea is familiar, a senior sponsor favors it or an available technology makes it attractive. Detailed engineering begins while the reason for choosing that approach remains largely untested.

Concept engineering provides a more disciplined basis for commitment. It develops several viable approaches, compares them against important needs and combines their strongest elements where doing so improves the solution.

Within Patient Centered Design, the purpose is to identify a concept that can help patients and healthcare professionals accomplish their jobs successfully. Question 2.1.1 examines the effectiveness of that work.

“A winning concept earns its place by addressing important needs and surviving comparison with credible alternatives.”

Start with a problem the team agrees on

Concept work begins with a concise problem statement and an agreed objective. Both should describe the progress the intended users need, rather than assume the answer.

An illustrative problem might concern a clinician’s difficulty identifying whether the information needed for a treatment decision is complete. “Build a new dashboard” commits to one response before exploring the problem.

Clarify the users, operating context and desired outcome. Review the patient journey and the clinical work surrounding the interaction. Establish which unmet needs the concept must address.

Resolve major differences in interpretation before the selection exercise. A mechanical engineer, clinician and commercial leader can otherwise compare ideas while quietly applying different definitions of success. Shared language makes their conversation more useful.

Bring priority needs into the criteria

Concept selection needs criteria grounded in research and requirements. Include the outcomes patients and professionals consider important, particularly those existing approaches satisfy poorly.

Then identify necessary capabilities and constraints. Relevant considerations may include safety, reliability, usability, manufacturing, service requirements, implementation and the resources available to develop the solution.

Separate mandatory conditions from characteristics that permit tradeoffs. A concept that cannot satisfy a necessary safety condition needs resolution or rejection; attractive performance elsewhere cannot compensate for that failure.

Define the criteria clearly enough for consistent comparison. “Easy to use” leaves the team guessing. The number of required actions, time to complete an activity or ability to recognize readiness can provide more concrete grounds for conversation, depending on the need.

Generate options before narrowing the field

Concept engineering encourages broad idea generation, with constraints applied more deliberately during selection. This gives the team room to consider alternatives before familiar solutions dominate.

Use sketches and short descriptions to make ideas visible. Invite different functions to contribute approaches, concerns and connections the team might otherwise miss.

The concepts should represent meaningful alternatives. Several versions of the same preferred design may leave the underlying assumptions untouched.

Explore how the required function could be achieved differently. Could information arrive earlier? Could preparation become simpler? Could a service change remove work the proposed product was intended to automate?

Make concepts understandable enough to compare

A concept should communicate its operating principle, important interactions and dependencies. A simple drawing can expose differences that remain hidden in a verbal description.

Explain what the patient or professional would do, what the system would provide and what supporting resources would be required. Include the activities before and after the visible product interaction.

Build enough detail to support the decision at hand. Early concept selection does not require complete engineering specifications, but an appealing image alone gives little basis for comparison.

Record what is known and what is assumed. If one idea appears stronger because its description omits difficult tasks, the matrix will reward an incomplete account of the solution. Consistent descriptions support a fairer evaluation.

Use a simple comparison matrix

The Pugh matrix provides a structured way to compare concepts. List the criteria as rows and the candidate concepts as columns. Choose a reference concept, known as the datum, against which alternatives will be assessed.

For each criterion, judge whether a concept is better than, similar to or worse than the datum. The simple notation is positive, same or negative.

Discuss the basis for each rating. Record supporting evidence and unresolved questions. The matrix makes differences visible and gives the team a shared place to examine them.

Totals can help identify promising candidates, but they should not make the decision automatically. The significance of a weakness depends on the criterion involved. Several small advantages may leave a concept unable to address its most important requirement.

“The matrix is useful when it exposes the reasoning behind a choice and the evidence still needed to defend it.”

Match the method to the available evidence

Early conversations often rely on incomplete information. Simple comparisons can be more useful than elaborate scores that suggest a level of precision the team does not possess.

Weighted methods may help when criteria genuinely differ in importance. Paired comparisons can support more structured judgments about relative priority. When measured engineering performance is available, use those data directly in the evaluation.

Choose the method for the decision and evidence, rather than adding complexity by default. Explain how weights or ratings were established and which assumptions could change the result.

Check whether the leading concept remains attractive under reasonable changes to uncertain judgments. A decision that reverses after a minor rating adjustment deserves closer examination before the organization makes a substantial commitment.

Look for stronger combinations

Hybridization is a central part of concept engineering. A concept with several strengths may also have a weakness another option handles well.

Examine whether the useful elements can be combined into a stronger approach. For an illustrative monitoring solution, one concept may support straightforward preparation while another provides clearer feedback when a connection fails.

A hybrid might preserve both benefits, but it needs its own evaluation. Combining features can introduce new interfaces, added complexity or conflicting operating requirements.

Redraw the combined concept and reassess it against the criteria. Investigate whether it actually removes the weakness or merely moves the burden elsewhere. The aim is a coherent design whose interactions work together, rather than an accumulation of everyone’s favorite features.

Manage disagreement as a source of learning

Concept selection brings technical judgment, professional experience and organizational interests into the same conversation. The quality of that conversation affects the outcome.

Agree on meeting ground rules and use a team with relevant expertise across functions. Ensure that a strong personality or senior title does not become a substitute for evidence.

When disagreement cannot be resolved, capture the question and define an action. Assign an owner, the evidence required and a completion date. An independent facilitator can help when team dynamics obstruct useful comparison.

The method can make judgments more transparent, but it does not eliminate subjectivity. Leaders should expect the team to explain its reasoning and show how important uncertainties will be resolved.

Test the assumptions that could defeat the concept

The leading idea may depend on uncertain technical performance, user behavior, supplier capability or implementation conditions that significantly affect time to market. Identify those dependencies before detailed development absorbs significant resources.

Plan focused experiments, research or prototypes to address them. Match each activity to a question that could change the selection decision.

If a concept depends on clinicians adopting a new preparation routine, a technical bench test will not establish that assumption. If it depends on a material performing under particular conditions, user enthusiasm will not resolve the engineering question.

Prioritize uncertainties with serious consequences for the concept’s viability. Early learning should help the team avoid expensive redesign while preserving options until the relevant evidence is available.

Select a direction with a clear explanation

At this point in the design process, using patient and healthcare professional journey mapping satisfies the Empathy stage of Design Thinking. Understanding the jobs to be done and desired outcomes satisfies the Define stage of Design Thinking. Concept engineering at its core is a practice that ensures the best solution direction is chosen before significant expense is incurred and satisfies the Ideate stage of Design Thinking.

With a selection of “winning concepts” in your pocket, complete the Design Thinking stages by rapidly prototyping and testing solutions with customers to gather data on which concepts your customers desire most. The Design Thinking stages provide an explanation of why a solution is preferred and a record of why alternatives were not chosen.

Retain the criteria, important comparisons, hybridization decisions and unresolved risks. This record helps future teams understand the consequences of a proposed change.

Selection establishes a direction for further learning and development. It does not prove that the solution meets user needs or performs safely in practice. Concept validation and subsequent engineering evidence must support those conclusions.

Keep the relationship with the original needs visible. A chosen architecture can gradually lose important benefits as specifications and implementation choices evolve. Traceability helps the team notice when a tradeoff undermines the reason the concept was selected.

Connect concept decisions with enterprise priorities

The Voice of Business and Voice of Technology should inform selection alongside customer evidence. A concept needs a realistic development route and an operating environment capable of supporting it.

A Value Management Office can connect these choices with resources and portfolio priorities. Systems thinking helps the team examine whether the proposed improvement addresses a constraint governing patient access or successful use.

Evaluate the complete contribution. A technically impressive device can introduce training, service or clinical work that limits its benefit in the wider pathway.

“Concept engineering should leave the organization with a reasoned choice, a manageable learning plan and a clear connection to patient benefit.”

What comes next

Review one current concept decision. Can the team show credible alternatives, agreed criteria, the basis for selection and the assumptions requiring further evidence?

Bring the relevant disciplines together, compare options and examine stronger combinations. Then test the uncertainties that could change the decision. That is how Patient Centered Design builds a defensible route from important needs to better products.