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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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[Background image: Guy walking the tightrope., on Shutterstock]
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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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