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The Value Management Office (VMO)

David Hodes, Founder

All improvement is change, but not all change is improvement. Organisations typically change because they want to improve their competitive advantage. How do we give ourselves the best possible chance of success?

[Listen to audio version, read by David Hodes]

Change resides in the domain of projects and project management. We most often think of the word project as a noun. But treat the word as a verb and we get a more accurate rendition of what projects are there to do—that is, to project a vision of an improvement into the future.

Even the simplest of businesses have many projects running at any given time, whether formally recognised or not. Larger organisations encompass marketing, business development, product and service development, technology, capital, business improvement, finance, HR and the list goes on. More sophisticated organisations govern many, if not all, of these initiatives through a Project Management Office, or PMO. These PMOs are usually organised along the lines of an accepted Project Management Body of Knowledge (PMBoK) and will cover areas such as scope, cost, schedule, communications, HR, risk, quality, procurement, stakeholder engagement and integration.

For what they do, PMOs are neither good nor bad; it depends on the capability of the executives charged with the managerial leadership of the function, and how much authority they have to define and fulfil its mandate. My experience, though, has taught me that the whole idea of a PMO is a necessary but not sufficient condition for delivering value. Those charged with running PMOs easily get side-tracked into getting better and better at their technical proficiency in planning and executing projects while losing sight of the value such projects are there to deliver. Or, as one wit put it, ‘great landing, wrong airport’.

“A PMO is a necessary but not sufficient
condition for delivering value”

Since all TOC implementations are projects, I have long wrestled with the conundrum of how TOC fits into the world of project management. On the one hand there is the obvious connection to Critical Chain Project Management, but on the other, there is so much more: Drum Buffer Rope, The Replenishment Solution, the Logical Thinking Process, Constraint Accounting. And then there is the deep question of how to bring these innovations in productivity into the day to day—how people learn how to use the methods and tools and what kind of organisational design liberates the full flow of value contained in the science of the theory.

Delivering value at scale
A few years ago, I developed a new model for the traditional PMO and called it the Value Management Office, or VMO. The primary purpose of the VMO, as its name implies, is to deliver value. Its architecture is designed to be scalable. At the highest level, it defines and governs global processes for all initiatives and projects. As the ultimate repository of value initiatives, it provides the framework, processes and capabilities required to ensure that the right initiatives are chosen and prioritised from amongst the many, and that they are successfully led and managed to their conclusion.

Importantly, the conclusion of any given initiative may not be the delivery of the end-product or service. Within the VMO resides the governance mechanism to define the stage-gates which articulate deliverables for each stage and ensure cancellation or delay if circumstances prove the initial assumptions invalid. Stage-gates are where projects go to die when they are no longer able to carry the burden of their initial expectations.

Furthermore, a critical part of the VMO is the idea of benefits tracking—that is, ensuring that what was promised as an improvement is actually delivered; and if not, then why. In a fundamental way, the VMO is an instrument of organisational learning and systems thinking that looks not only to improve on the given way of doing work, but to ask the question about how to continuously innovate for better ways. These better ways can be achieved through questioning assumptions about existing methods or inventing new methods based on a vision of what the future can teach us.

At Ensemble, we have designed the VMO with twelve interacting panels—akin to the instrumentation of a complex piece of technology.

These twelve tiles are grouped together under four major themes:

VMO operating system

  • Definition: defining demand for your capabilities in and across time and place
  • Preparation: preparing your resources to supply the capability to meet that defined demand
  • Optimisation: optimising the proposed resources in good time, for the duration of the work
  • Performance: performing work, addressing both its planning and execution in a coherent and synchronous fashion

In a final grouping together, these four pillars of the VMO resolve into the central idea of ‘Plan the Work’ and ‘Work the Plan’.

Let’s take a closer look at the individual tiles and try to understand them through the questions each tile is designed to resolve:

Value Management Office

PhaseTileQuestions
DEFINITIONGovernance & Standards- Who’s in charge?
- Under what authority?
- How do policies get set, implemented and changed?
Context, Purpose & Scope- How does the project fit into the bigger picture?
- Why do it at all?
- What’s in and what’s out?
ICT Management & Version Control- What technology will help you plan and perform the work?
- How do you control files, code and other project artefacts?
PREPARATIONLearning, Leadership & Culture- How will you inspire your teams to learn together?
- How will new ways of working be accepted into your culture?
Mindset & Behaviour Analytics- How can you objectively assess team performance?
- How do high-performance teams think, feel and act?
Accountability Hierarchies- From CEO to frontline, who carries the can?
- How do you give people ownership, yet keep control?
OPTIMISATIONPlanning, Scheduling & Process Management- How do you decide who works on what?
- By when?
- How do you define and control the development of processes?
Resource Management- What capabilities do you need in your project pool?
- How will people come on and off the project?
- At what cost?
Scenario Testing- Scope, cost, schedule? How do you decide the best trade-offs?
- Which scenarios are most relevant to the business needs?
PERFORMANCEWays of Working- How do you keep everyone in sync? 
- What are your meeting rituals?
- Who attends?
- When, and why?
Reporting & Analytics- How do you instrument and control the creation of value?
- How do you use data to improve performance?
Requirements & deliverables tracking- How do you map completed work to required outcomes?
- How do you manage changes to the baseline plan?

To systemically improve production, Theory of Constraints itself is necessary but not sufficient. To harness its power, it’s best to systematically address all the core ideas contained in the tiles, which represent an operating system for your organisation. By design, you would want an overarching VMO that acts as the repository of standards, processes, governance and knowledge for the organisation as a whole. The architecture of a VMO should allow for strategic business units to have their own satellite VMOs, responsible for maintaining systemwide standards, but developing documentation and guidelines specific to those units where deemed necessary.

Standardisation is not about everyone marching in lockstep within a mechanical system but rather about serving the higher objectives. Think of it as moving up a ladder of capability. You want to put foundations in place that can apply to the next project so people don’t have to reinvent that part of the system every time. Musicians build their technique through scales, arpeggios and etudes but the goal is to use them to help make music. Formalising elements of the operating system expressed in the VMO tiles creates better soil in which ideas and people can learn and grow.

One of the problems of trying to organise work is that of classification. It exists in every sphere of life. Think of a library of books. You can store them by author, by title, by year published, by genre, by language, by number of pages, by the colour of the cover, by the type of paper it’s printed on, by the font used, by author’s birthday, by popularity, by physical size, and on and on it goes. To store and retrieve books in a consistent, universally usable way was a problem largely solved in the nineteenth century by Melvil Dewey and his Dewey Decimal Classification.

“The VMO turns theory into practice
while measuring tangible business benefits”

Unfortunately, there’s no universal agreement on the perfect way to order the world of work. I view the system of the VMO as a constant work in process. If your processes are too rigid and try to cover every eventuality, the organisation becomes sclerotic, unable to improvise when a new situation inevitably occurs. But if you put off the work of defining standards, you lurch from one crisis to the next, never leaving the realm of the chaotic. Jazz musicians typically decide in advance on structure and tempo by choosing a tune and counting it off. They are then free to create something new together.

Building the learning organisation
As I wrote above, the VMO is an artefact of the learning organisation and is therefore subject to the well-worn rhythm of the plan-do-check-act cycle. It’s a theory of how to organise a better way to do better work. And, as the doyen of systems thinking, W Edwards Deming, put it: ‘Experience by itself teaches nothing. […] Without theory, experience has no meaning. Without theory, one has no questions to ask. Hence, without theory, there is no learning.’

The VMO turns theory into practice while measuring tangible business benefits, such as the realisation of value through increased throughput, lower operating expense, superior ROI, faster speed to market and more reliable delivery to promise.

To take the first step down this route, you could get together with a colleague or two and go through all twelve tiles. Simply ask yourselves the questions, noting how you currently address these issues—and how consistently successful your organisation is at handling them.

____________________________

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)
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    “Try not to become a man of success,
    but rather try to become a man of value”
    —Albert Einstein

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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.

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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

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