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Imagine being the conductor of an orchestra and having to make your baton signal for every note of every musician, from beginning to end. Impossible, no? Now try and imagine the musicians playing without the guiding hand of the conductor to keep everyone sounding together—louder and softer, faster and slower, entrances and exits. This is the dilemma we face in our projects. We need to understand the ‘score’ in two tiers.
The top tier represents the fundamental shape of the project—the path from beginning to end—along with the resources for each task. In our orchestral analogy, the resources are the different parts of the orchestra—strings, woodwind, brass and percussion—while the conductor ‘assembles’ the musical phrases across the ensemble to create a mellifluous whole.
The second tier on the other hand is the detail each musician deals with. The second tier comprises the individual notes conceived of by the composer—each contributing to the effect on the listener—put together skilfully by each practitioner. We want our musicians to have mastered their instruments, and to use that skill to liberate themselves to turn the notes into phrases that stir the emotions.
It’s not enough to merely play out the algorithm of the notes on the stave—they must hold together, in both timing and harmony with all the other notes of the composition, to create a whole that is more than the sum of its parts. It’s really an extraordinary feat of human accomplishment to have perhaps a hundred musicians or more performing as one to achieve the intent of the composer.
The enigma of variation
In a project setting, Critical Chain 1.0 provided the means by which the top tier could be effectively managed. Goldratt captured the risk associated with what Deming characterised as ‘common cause variation’ and aggregated it in a buffer at the end of a resource-levelled chain of tasks. The work could then be monitored to check the rate at which the actual work was being completed against the rate at which the aggregate protection was being consumed.
In Goldratt’s original idea, he was there to solve the problem of finite capacity whilst labouring in the real world of uncertainty. You know that Murphy is always going to strike—you just don’t know where. The effect of a delay, using CCPM, can be effectively traced back to the specific task causing it. Focus the effort on that task, at the bottleneck, and it becomes possible to increase project throughput. This was a huge innovation in productivity. The benefits were shorter completions which realised the early receipt of benefits, incurred less project burn and allowed the organisation to deploy people to the next big idea sooner.
“You know that Murphy is always going to strike—
you just don’t know where”
However, when it came to the detail, matters tended to get too complex; different means (such as spreadsheet support) had to be used to articulate the detail. This was not particularly satisfactory, even though the results were a massive improvement on the critical path method which preceded it.
Thanks to pioneering work done by the likes of Sanjeev Gupta and Wolfram Muller we now have a robust framework for two-tier scheduling, extending the breakthroughs of Critical Chain Project Management for a whole new range of applications—and even better outcomes for those who have already started their CCPM journey.
Below is a brief explanation of the technical breakthrough of two-tier scheduling, with the assumption that you have read our executive guide to critical chain or know what it is through some other means. If you prefer to watch a video to get the basics of critical chain and buffer management, have a look at this video called Keeping Control in Real Time from our Science of Work playlist.
In the diagram, our project has three top-tier tasks, coloured in blue. Each represents a bucket of work which can be handed to a supervisor to complete. (We’ll assume you know typical task durations and are using the critical chain concept of pure touch-time, with no padding.) Within each bucket are four tasks, though there could be more. The different colours represent different resource types and their lengths represent their duration.
The nature of the tasks gathered under top-tier task 1 is such that they have to be done sequentially. Top-tier task 2 has enough resources available for two tasks to run at a time, so the red and yellow second-tier tasks can start together. But only once the first is complete can the next one start. Work-in-process (WIP) is therefore released in a controlled way. (WIP control doesn’t have to be restricted to two concurrent tasks; it depends on the available capacity.) Note also that the black task starts before the green in this case. We’ll come back to this a little later. The tasks in the last bucket (top-tier task 3) can all run in parallel, so its duration is determined by the task which takes the longest—in this case, the yellow one.
(Naturally, parallel work requires more resources, while the WIP-controlled mode lets you pace the work to your capacity. In many cases, logic will dictate when you must use the sequential mode but you might sequence work deliberately to use fewer resources. The work will take longer, but if the task isn’t on the critical path that may be fine.)
The overall duration of the schedule is thus a critical chain of 10 days and a buffer equal to half as much again (the standard calculation for a project buffer), making a total elapsed duration of 15 days. The project manager now has a plan resolved at the right level of resolution to execute the work. He or she is the equivalent of the conductor I talked about above. Their role is to monitor the progress of the top-tier tasks only, doing whatever is necessary to keep the work in flow towards the desired end-date.
Devolving authority to those doing the work
Beneath the top tier, so long as the participants keep within the bucket of activity and duration scheduled, they have the autonomy to organise their work as they judge to be in the best interests of the project as a whole. There are no hard dependencies between tasks within a top-tier bucket, as it is never so complex that the task manager in charge of the bucket cannot make a determination based on his or her own knowledge. The whole point of gathering second-tier tasks into a bucket is that they can be adjusted to take account of the situation in the moment.
Two situations can illustrate when this autonomy can be exercised. Let’s say that one of the tasks in the list is to overhaul a motor, and another is to isolate the electricity from the motor before starting the work. The task manager of any top-tier task would understand the work well enough to ensure the second-tier tasks were arranged in such a way as to ensure correct precedence was followed. If a sequential mode hadn’t been chosen, the task manager for, say, top-tier task 2 (the bottom bucket in our diagram) would arrange the second-tier tasks for safety, quality and speed, as part of the full kitting of the task.
“The dynamic shifts from ‘command and control’
to one of enrolled engagement.”
Look again at top-tier task 1 and top-tier task 2 which are themselves proceeding in parallel as work buckets. The order of the black and green tasks has been switched to remove the contention for the green resource. This is possible because the task manager for top-tier task 2 has the autonomy to determine which two tasks to put into WIP. On Day 4, we can see that yellow resources are required across two top-tier tasks. This might mean some levelling is required between those two top-tier tasks. It might also be possible to take resources from elsewhere in the system and apply them to that single overlapped day requiring yellow resources.
This is a simplified example. In real life, these kinds of calculations would quickly become cumbersome and complex beyond human brainpower. Fortunately, dedicated software is here to help. At Ensemble, we are proud to be associated with and represent Realization Technologies, pioneers in the art and science of execution management using the Theory of Constraints and Critical Chain Project Management (CCPM). With the Concerto tool (Realization’s CCPM software), you can input your workplan and then toggle between the different modes (sequential, parallel, WIP-controlled) to instantly see the tradeoffs between schedule and resource consumption (cost).
An ‘Agile Work’ manifesto
I should note that two-tier scheduling is absolutely not the same as the levels of a traditional work-breakdown structure (WBS) such as you might see in MS Project. There, work is organised much like a book’s table of contents, expanding from parts to chapters to sub-sections. But that’s just a way to collapse a Gantt chart. Two-tier planning, on the other hand, is a way of organising work such that you can maintain the shape of the network at the appropriate level of detail to ensure you navigate effectively to your goal. It also provides the people doing the work with all the detail they need in terms of work orders and operations.
A primary motivator for people at work is to have autonomy and be trusted to do the right thing by the team. The two-tier scheduling method gives those who manage the top-tier task high levels of autonomy to execute the second-tier tasks, but within the guardrails required to keep the overall project on track. They are encouraged to work with the people actually carrying out the tasks, to figure out what’s best for the whole. The dynamic shifts from ‘command and control’ to one of enrolled engagement.
It is not difficult to see how such a method can be used to powerfully combine the best of Agile and Waterfall methods. After all, what is contained in the top-tier task is really a series of Agile story points. And you could easily think of a top-tier task as a sprint. Two-tier scheduling therefore builds on what Wolfram Muller calls ‘Reliable Scrum’. In fact, we’d go so far as to tweak the original Agile Manifesto, overwriting some of the words with our own. Call it our ‘Agile Work’ manifesto—an invitation to a world of More Than Just Work.
Ensemble’s Agile Work manifesto
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What’s next?
The change from standard thinking to Theory of Constraints (TOC) is both profound and exhilarating. To make it both fun and memorable, we use a business simulation we call The Right Stuff Workshop.
We’d love to run it with you. To learn more:
- download the brochure (no email required)
- schedule a call
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[Background photo: ‘What path to take’
by Abraham Barrera on Unsplash]“Nothing is more powerful than
an idea whose time has come”
—Victor Hugo
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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