Ensemble Ensemble
Menu
Home
  • SOLUTIONS
  • Method
    • A Systemic Approach
    • Theory of Constraints
    • Working with us
  • RESOURCES
    • Productivity Scorecard
    • Articles
    • Subscribe
    • Our book
  • Results
  • ABOUT
    • The Just Work Manifesto
    • Our Story
    • Location
Book a call
loader

Language | Operations | Process | Resources | Strategy

View all articles SUBSCRIBE TO NEWSLETTER to get articles and more

STAY CONNECTED AND SIGNUP TO RECEIVE INSIGHT updates

Subscribe

The measure of money

David Hodes, Founder

Whatever you think about the free enterprise system, making more money now and in the future is a cornerstone for those for-profit companies who participate in it. Let’s look at how TOC can fundamentally shift management thinking and achieve ever better returns on shareholder funds. By using the systems-based measurements of Constraint Accounting, you will be equipped with the means to make better decisions.

The reason we have financial measurements in the first place is to ensure that we make better financial judgements for our organisations. These judgements can fall into five basic categories:

[Listen to audio version, read by David Hodes]

  • Investment decisions—what should I be investing in to ensure I am getting my best possible return on shareholder funds?
  • Product and service decisions—which mix of products and services will maximise my organisation’s profits?
  • Evaluating profit centres—how do I know which profit centre is doing well and which is doing poorly?
  • Make/buy decisions—should I be making a product or developing a service form within my organisation or should I buy them out from a third party?
  • Pricing—what price should I be charging for the goods and/or services I offer into the market?

Let’s get some definitions down. The basic financial measures of TOC can be articulated by the formula below:

 

ROI = return on investment
T = throughput, or sales less truly variable costs (referred to by cost accountants as contribution margin)
OE = operating expense, defined as labour plus overheads
I = investment

Throughput less operating expense equals profit, and hence (T – OE)/I is profit divided by investment (or ROI). The goal of a for-profit organisation is to maximise return on investment—both now and in the future. To do this, it must meet certain necessary conditions, such as satisfying shareholder investment criteria, engaging staff in the vision, mission and purpose of the organisation, and ensuring good, healthy relationships with suppliers and regulators.

The troubles begin with the unexamined assumptions we make about our existing accounting systems. Fundamentally, whether you are in the world of projects or production, the prevailing paradigm has us break up the whole into constituent parts to try and tame complexity. We use methods in our management accounting which call for earned value in projects and absorption costing in production. Both methods are fundamentally the same; they seek to ascribe value to activity, regardless of whether the activity is at the constraint or not.

All organisations have constraints,
or else their profits would be infinite.

No less an authority than the late Stanford professor and management accounting academic Charles T Horngren made the case that: ‘Relevant information is the predicted future costs and revenues that will differ among alternative actions. The existence of a limiting factor changes the basic assumptions underlying the cost and revenue opportunity of a particular action.’

Stated another way: An organisation will maximise profit when it sells the product or service with the highest contribution margin (throughput) per unit of the constraint.

This idea is self-evidently true. All organisations have constraints, or else their profits would be infinite. The corollary is that non-constraints must then, by definition, have ‘excess’ capacity available. But this is not the way the majority of finance departments look at the world. They generally ignore the contribution made by the scarce resource, and indeed wouldn’t know what the scarce resource was, nor what to do with it, if it were to jump up and announce itself with megaphone in hand.

Most finance folk obsess about cost drivers, firm in their belief that knowing and reducing the unit cost of a product or service will maximise profits. They struggle mightily to achieve what in the business is called the ‘matching principle’—that is to match the revenue in a given financial period with the costs incurred in that period. Revenue less costs is, after all, the definition of profit. But they’re looking at the wrong thing.

Whose rules are you playing by?
Because Finance sets the rules of the game, Operations ends up chasing down their local efficiencies, assuming that a penny saved here and another saved there will all add up to what the scorekeepers say is important. There is a nagging feeling, though, that something is amiss—are they not all trying to make money for the organisation and not merely save costs? Is the additive weight of the links in the value chain what’s important, or is it the strength of the weakest link which determines how much value can be pulled through?

Marketing and Sales are also caught in this dilemma, struggling to sell the product or service with the highest gross margin per unit (selling price less fully absorbed cost). Finance fears that Sales will give away all the margin they have just to get the deal. The finance folk, therefore, load the ‘cost’ of the product or service with as much labour and overhead burden as they can muster. When the product or service is eventually sold, Finance is confident that as a consequence of absorbing all the costs the accounting conventions and policies allow, the organisation will maximise its profits. But their comfort is misplaced.

Even worse, by absorbing the operating expense into the cost of a product or service, this accounting sleight of hand credits an operating expense to profit. This operating expense moves miraculously to the balance sheet as an asset, whether it’s Work in Process (WIP) trapped in the system, or finished goods no one wants to buy. It becomes very tempting to overproduce so that more and more operating expense can be converted into inventory, or ‘earned value’, meanwhile converting precious cash into warehouses full of product and taking focus off the critical paths of projects.

The dilemma about whether or not using product or service cost leads to maximising profit is articulated in the ‘evaporating cloud’ below:

If we can all agree on the idea that the organisation is looking to maximise profit, then in the entities B and C, we have the necessary conditions of ‘maximise throughput at the constraint’ and ‘maximise the difference between revenue and cost’. In the entities D and D’ we have the dilemma: ‘abandon absorbed product or service cost’ versus ‘use absorbed product or service cost’?

There’s no issue with profit maximisation coming from maximising the difference between revenue and cost. Indeed, that statement is not in conflict with the idea of maximising throughout at the constraint—they are mutually supportive necessary conditions for maximising profit.

Where the argument breaks down is in the assumption between C and D’. It says that in order to ‘maximise the difference between revenue and cost’, we must ‘use absorbed product or service cost’, because ‘according to the matching principle, I must absorb periodic fixed costs into the cost of my products or services so I can determine product or service profitability’.

If all of this sounds a bit technical, let’s look at a simple example. Let’s say Product A has a fully absorbed cost of $10—that is, all materials and absorbed operating expense comes in at $10, and it takes 1 hour to produce this product, which you sell for $20. Your gross profit is $10 per hour. Now, if product B only makes $1 of gross profit per unit—calculated on the same basis as for product A—but it takes only 5 minutes to produce, then, all other things being equal, we will end up making $12 profit per hour—a 20% improvement simply by selecting our sales choices according to the principle of maximising throughput.

The idea of being able to determine the cost of a product or service based on production volume, and the allocation in a given accounting period of an often arbitrary operating expense burden, is the accountants’ equivalent of Don Quixote tilting at windmills.

We often fail to examine our assumptions—no less so in business than in any other walk of life. The decisions we make, based on unexamined habits of thought, can have fateful consequences for organisational performance. We are handed a set of measures by the accountants and assume that in reading them we will have a good idea about how to go about making sound financial judgements. But reading the financials and thinking you know what’s really going on in your organisation is like going to your favourite restaurant and eating the menu to understand the taste of the meal.

If you want to learn more about how TOC can help you focus where it really counts, why not schedule a video call.

____________________________

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

    ____________________________

    What path to take
    [Background photo: ‘Vintage cash register’
    by Ramiro Mendes on Unsplash]

    “Money stinks, but I like the smell”
    —Paulette Hodes (mum)

  • Culture
  • Operations
  • Process
  • Strategy

The healthcare professional: the hidden constraint in patient flow

Ensemble Administrator

Healthcare professionals are central to the patient’s progress from awareness of a therapy to successful long-term use. They identify risk, interpret evidence, diagnose conditions, discuss options, perform procedures, provide training and monitor outcomes.

Yet many medical device development programs treat healthcare professionals primarily as users to be trained or customers to be persuaded.

HCP-Centered Design takes a wider view. It examines the work healthcare professionals must perform, the system in which they perform it and the constraints that limit their ability to move suitable patients through the care pathway.

“If patient flow depends on a healthcare professional, that professional’s available capacity may determine how many patients ultimately receive the therapy.”

Healthcare professionals govern critical transitions

A medical device patient journey commonly depends on several healthcare professionals:

  • A primary care professional recognizes a problem or makes a referral.
  • A specialist assesses the patient and manages the disease pathway.
  • Diagnostic professionals generate and interpret evidence.
  • A managing physician supports authorization or reimbursement.
  • An interventional specialist confirms eligibility and performs a procedure.
  • Nurses, educators or allied health professionals help the patient adapt.
  • Follow-up teams monitor efficacy and coordinate adjustments.

Each professional governs a transition in the flow of patients.

If one transition lacks sufficient capacity, information or clarity, the whole pathway slows. More marketing, sales activity or production capacity will not compensate for a shortage of specialist time or a burdensome diagnostic process.

This is why HCP-Centered Design is not simply about making an interface easier to use. It is about enabling the system of care to perform.

The HCP works within a system

A healthcare professional’s work depends on information and actions supplied by others. They may rely on referrals, patient histories, pathology, imaging, electronic records, clinical guidelines and the availability of equipment or trained colleagues.

After reaching a decision, they may need to explain it, document it, arrange authorization, coordinate treatment and prepare the next person in the pathway.

A technically strong solution can still create difficulty if it:

  • Requires information that is hard to obtain
  • Interrupts established clinical workflows
  • Produces outputs that are difficult to interpret
  • Adds documentation without removing other work
  • Fails to connect with existing systems
  • Demands training that cannot be sustained
  • Transfers work or risk to another professional
  • Provides a result without clarifying the next action

The relevant design question is not merely, “Can the HCP use this product?”

It is, “Does this solution improve the HCP’s ability to complete important clinical work within the conditions in which care is actually delivered?”

Identify the real healthcare professional personas

“HCP” is not one persona.

A general practitioner, specialist, interventional physician, nurse, technician and clinical administrator encounter different stages of the pathway. Each has different responsibilities, authority, expertise and exposure to risk.

Even within a profession, context matters. An experienced specialist in a major hospital may approach the same task differently from a professional who encounters the condition infrequently or works without immediate specialist support.

Useful HCP personas distinguish factors that influence work:

  • Clinical responsibility and decision authority
  • Frequency of encountering the condition
  • Experience with the procedure or technology
  • Access to information and specialist support
  • Available time
  • Confidence in interpreting results
  • Responsibility for follow-up
  • Exposure to clinical, legal or financial risk

These personas clarify who performs each job and what support each person requires.

Map the HCP journey

The HCP journey often begins before the visible clinical procedure.

It may include receiving a referral, gathering information, forming an initial view, ordering investigations, interpreting results, deciding whether the patient is eligible, discussing treatment, obtaining authorization, preparing for the procedure, delivering care and arranging follow-up.

At each stage, ask:

  • What is the HCP trying to accomplish?
  • What information is required?
  • Where does the information come from?
  • What decision must be made?
  • What could cause delay or rework?
  • Who depends on this action?
  • What must happen before the patient can progress?

The resulting journey map should distinguish processing time from waiting time. A decision may require only minutes of specialist attention while patients wait weeks to access that attention.

This reveals the practical relationship between HCP capacity and patient flow.

Find the HCP constraint

The Theory of Constraints directs attention to the factor limiting the performance of the entire system.

In some pathways, the constraint may be the number of qualified interventional specialists. In others, it may be diagnostic capacity, physician confidence, authorization effort, operating room access or the time required to train patients.

The constraint may also be hidden inside the HCP’s working day.

A specialist supporting a therapy must still manage other clinical duties, administration, meetings, documentation and urgent cases. The question is not simply how many specialists exist. It is how much of their usable capacity is available for the activities upon which patient flow depends.

“The scarcest resource may not be the healthcare professional. It may be the few hours of focused capacity available for the critical work.”

Improvement away from this constraint can make performance worse. Sending more referrals to an already overloaded specialist increases the queue. Adding information may increase cognitive burden. Creating another approval may consume the capacity required to treat patients.

HCP-Centered Design seeks to protect and expand the capacity that governs flow.

Go to the clinical Gemba

Policies and procedures describe how clinical work should happen. Observation reveals how it actually happens.

Healthcare professionals routinely compensate for missing information, awkward interfaces and unreliable handovers. These workarounds may become so familiar that nobody reports them as problems.

Gemba research should examine:

  • How the HCP prepares
  • Which tools and information sources are used
  • What interrupts the work
  • Where the HCP waits or repeats activity
  • How uncertainty is communicated
  • What must be documented
  • How work passes to the next person
  • How the HCP recognizes that the job is complete

The purpose is not to judge the healthcare professional. It is to understand the system surrounding the work.

“A workaround is often evidence that the system has failed to support the person doing the work.”

Define the HCP’s job to be done

Healthcare professionals do not simply use devices. They use them to make progress in clinical work.

An HCP may need to identify risk, reach a confident diagnosis, select an intervention, perform a procedure safely, explain options, monitor progress or recognize deterioration.

A structured job map divides this work into eight stages:

  1. Define the intended clinical outcome.
  2. Locate the necessary information and resources.
  3. Prepare the patient, equipment and environment.
  4. Confirm readiness and choose between alternatives.
  5. Execute the clinical activity.
  6. Monitor its progress and results.
  7. Modify the approach when circumstances change.
  8. Conclude, document and prepare for subsequent care.

This wider view prevents the product team from concentrating exclusively on the procedure.

The greatest value may come from reducing preparation, improving decision confidence, clarifying an exception, simplifying documentation or improving the handover to follow-up care.

Convert experience into measurable outcomes

Comments such as “the interface is difficult” or “we need better information” indicate dissatisfaction, but do not provide sufficient direction for design.

They should be translated into measurable outcome statements, such as:

“Minimize the time required to identify which clinical information is missing before making a treatment decision.”

Or:

“Reduce the likelihood that a clinically significant change goes unrecognized between scheduled reviews.”

A broader population of healthcare professionals can then assess the importance of each outcome and their satisfaction with their current ability to achieve it.

Highly important and poorly satisfied outcomes provide a rational basis for prioritizing innovation.

“Adoption follows when a solution makes important clinical work safer, clearer or easier to complete.”

Apply FOCUS to HCP capacity

The five-step FOCUS process creates a practical improvement cycle.

Find the constraint. Determine which HCP activity or resource currently limits patient flow.

Optimise for it. Protect the constraint from avoidable work, missing information, interruptions and rework.

Collaborate around it. Align upstream and downstream teams so patients, information and resources arrive when required.

Uplift it. Add capacity, redesign responsibilities, improve technology or remove restrictive policies.

Start Again. Identify the new constraint once flow improves.

This approach allows the organization to distinguish activity from value. It also turns HCP engagement into an ongoing management discipline.

Connect HCP evidence with enterprise execution

HCP-Centered Design must connect clinical reality with patient needs, technology, regulation and business strategy.

A Value Management Office can help coordinate these perspectives across the product lifecycle. Its role is to ensure that projects, resources and stage-gate decisions remain connected to patient flow and business value.

The organization should be able to show:

  • Which HCP groups influence the pathway
  • What each group is trying to accomplish
  • How the work happens in practice
  • Which outcomes remain poorly served
  • Where HCP capacity constrains patient flow
  • How the proposed solution changes the wider care system
  • How improvement will be measured

The goal is not simply a device that healthcare professionals can operate. It is a solution they can confidently incorporate into care and a delivery system capable of getting that solution to more patients.


What’s next?

Use the HCP-Centered Design assessment to determine how well your organization understands clinical work, HCP capacity and the constraints governing patient flow.

The resulting evidence should guide product design, process improvement and investment toward better products, delivered faster, with more lives changed for good.

READ MORE

  • Operations
  • People
  • Process
  • Strategy

Patient flow: the missing system in Patient Centered Design

Ensemble Administrator

Medical device companies devote enormous skill and investment to developing safe, effective products. Yet a technically successful device changes no lives while suitable patients remain unable to reach it.

Between a patient becoming aware of a therapy and receiving its intended benefit lies a pathway of referrals, consultations, diagnostics, approvals, procedures, training and follow-up. Every step consumes time. Between the steps, patients wait. At some points, they become confused, discouraged, ineligible or lost to the process.

Patient Centered Design must therefore address more than the design of the device. It must improve the performance of the entire system through which patients reach, receive and live successfully with the solution.

“A life-changing therapy changes no lives while patients remain trapped in the pathway leading to it.”

The patient journey is a flow system

A typical medical device journey may include:

  1. The patient becomes aware of a possible therapy.
  2. A primary care professional or specialist assesses the patient.
  3. Diagnostic work determines whether the therapy is appropriate.
  4. The patient secures authorization or reimbursement.
  5. An interventional specialist confirms and plans the procedure.
  6. The patient receives the device or therapy.
  7. The patient learns how to live with the solution.
  8. Follow-up identifies any necessary adjustments.
  9. Periodic reviews monitor longer-term efficacy.

Companies often manage these stages as separate functions. Marketing works on awareness. Medical affairs supports clinicians. Market access addresses reimbursement. Sales works with specialists. Clinical teams gather evidence. Training teams support adoption.

The patient, however, experiences one journey.

From the patient’s perspective, a delay between two organizational functions remains a delay. A repeated test remains repeated work. An unclear handover creates uncertainty regardless of which department owns it.

Patient Centered Design begins when the organization sees and manages this journey as a connected system.

Processing time tells only part of the story

Every step contains some necessary processing time. A consultation takes time. A diagnostic test takes time. An authorization must be assessed. A procedure must be performed.

The patient’s total lead time, however, also includes the waiting between these activities.

A consultation may take 30 minutes, but the patient could wait six weeks for it. A diagnostic test may take an hour, followed by another delay before a specialist reviews the result. Prior authorization may require little actual work while adding weeks to the pathway.

This distinction matters because organizations often improve processing time while leaving the larger queues untouched. Saving five minutes during an appointment produces little benefit if the patient waits months to reach it.

Patient Centered Design therefore asks:

  • How long does each activity take?
  • How long do patients wait between activities?
  • How many suitable patients enter each stage?
  • How many progress to the next stage?
  • Where and why do patients leave the pathway?
  • How much total time passes before the patient receives the solution?

The answers reveal the true performance of the patient system.

Find the constraint

Theory of Constraints teaches that the performance of any system is limited by a constraint. Improving a part of the system that is not constraining flow may create more activity without increasing results.

If diagnostic capacity is the constraint, generating more awareness may simply produce a longer queue for diagnosis. If specialist capacity is the constraint, accelerating authorization may move patients more quickly into another wait. If training after first use is inadequate, increasing procedures may produce poor experiences and avoidable follow-up demand.

“More activity at a non-constraint creates work in process. More capability at the constraint improves the system.”

The constraint is not always a physical resource. It may be a policy, an eligibility rule, missing evidence, a fragmented handover, an information delay or the cognitive burden placed on the patient.

The most important question is therefore not, “How do we improve every step?”

It is, “What currently limits the flow of suitable patients to successful use of the therapy?”

Understand why patients remain in or leave the flow

Numbers show where patients are lost. Patient research helps explain why.

Two patients with the same diagnosis may respond very differently. One may actively seek new treatment options. Another may delay action until symptoms become severe. A third may want help but lack confidence in navigating the healthcare system.

Meaningful patient segmentation considers characteristics that influence behavior:

  • The importance the person gives their health
  • Their confidence in dealing with healthcare professionals
  • Whether they act independently or need encouragement
  • Their comfort with technology
  • The pressures of work, family and daily life
  • Their ability to understand and act on clinical information
  • Their willingness and ability to pay
  • The outcomes they most want to achieve

These differences affect whether patients enter the pathway, remain engaged and successfully adopt the solution.

Go to the patient’s Gemba

The Gemba is the place where work actually happens. For patients, this includes the home, clinic, hospital and all the places where they manage their condition between formal encounters.

Interviews alone may miss important evidence. People normalize inconvenience, forget workarounds and simplify their past decisions. Observation allows the development team to see what patients actually do.

Good research combines three activities.

Observe. Watch how patients obtain information, prepare, use the solution and respond when something goes wrong.

Immerse. Understand the physical, emotional and practical conditions surrounding the experience.

Engage. Ask open questions that allow patients to describe their goals, fears and frustrations in their own language.

The purpose is to discover the patient’s reality before asking them to evaluate the organization’s preferred answer.

Understand the patient’s job to be done

Patients rarely want a medical device for its own sake. They want the progress it may enable.

They may want to recognize deterioration earlier, preserve independence, reduce pain, avoid repeated visits, return to work or prevent a disease from controlling daily life.

A useful job map examines eight recurring stages:

  1. Define what must be achieved.
  2. Locate the required information and resources.
  3. Prepare for the activity.
  4. Confirm readiness and choose between alternatives.
  5. Execute the activity.
  6. Monitor whether it is working.
  7. Modify the approach when circumstances change.
  8. Conclude or prepare for what follows.

This reveals opportunities beyond the immediate use of the device. The most valuable improvement may involve helping patients prepare, confirm readiness, recognize an exception or understand what happens next.

Turn patient experiences into evidence

Stories create understanding, but investment decisions require structured evidence.

Patient observations and comments should be converted into outcome statements that identify:

  • The desired direction of improvement
  • A measure of success
  • The object being controlled
  • The circumstances in which it matters

For example:

“Minimize the time required to recognize that my condition has changed sufficiently to require clinical help.”

Patients can then assess the importance of each outcome and their satisfaction with their current ability to achieve it.

Highly important and poorly satisfied outcomes represent genuine opportunities. This prevents teams from prioritizing attractive features that do not materially improve the patient’s life or progress through the pathway.

“Innovation becomes valuable when it improves an outcome that matters and remains poorly served.”

Apply the five-step FOCUS process

The Patient Centered Design pathway can be improved through a repeating discipline:

Find the constraint. Identify what currently limits patient flow or successful use.

Optimise for it. Make the best possible use of existing constraint capacity.

Collaborate around it. Align functions and partners so their actions support the constraint.

Uplift it. Add capability, remove restrictive policies or redesign the pathway.

Start Again. Once the constraint moves, identify and address the next limiting factor.

This prevents improvement from becoming a collection of disconnected initiatives. It directs scarce resources toward the factor that most strongly governs the result.

Patient Centered Design is an operating system

Patient insight should influence more than early product design. It should shape clinical evidence, regulatory strategy, reimbursement, manufacturing, education, market development and post-market support.

The organization should be able to show:

  • Which patients it intends to serve
  • What those patients are trying to accomplish
  • How the complete patient pathway operates
  • Where patients wait or leave the flow
  • Which outcomes remain poorly served
  • What currently constrains successful patient access
  • How the proposed solution improves the whole system

The goal is not simply to place the patient at the center of a diagram. It is to organize the enterprise around delivering better products faster, so that more lives can be changed for good.


What’s next?

Use the Patient Centered Design assessment to determine how well your organization understands its patient journeys, priority outcomes and constraints to patient flow.

The result should be more than another collection of patient opinions. It should provide evidence that directs strategy, investment and execution toward the changes that matter most.

READ MORE

More than just work

Discover better ways to do better work.

Fresh insights, every Friday

We alternate our own actionable articles with three relevant links from other authorities.

We’ll only use your email address for this newsletter. No sales calls

    Subscribe to 'Perspectives'

    [recaptcha id:cf7note]

    More Than Just Work
    Weekly productivity insights

    Subscribe
    • EnsembleConsultingGroup
    • Share Page
    • +61 2 9387 3955
    • info@EnsembleConsultingGroup.com

    Site proudly designed by Brand Fibre

    What is to get in touch with you?



    More than just work

    Discover better ways to do better work.

    Fresh insights, every Friday

    We alternate our own actionable articles with three relevant links from other authorities.


    We’ll only use your email address for this newsletter. No sales calls

    white_arrow white_bidirection_arrow arrow-right-green arrow-right-orange arrow-right arrow-left blue_arrow blue_round_arrow tick

    Want us to get in touch with you?

     
    Thank you for your interest. We will call you back.