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Peter Drucker quipped, ‘Business has only two functions—marketing and innovation.’ Early in my career, I focused obsessively on innovations in productivity. The really hard part, though, is convincing an organisation that a better way of delivering greater productivity exists. Allow me to try.
[Listen to audio version, read by David Hodes]
Recently, I was talking with a mate who happens to be an old client of mine. I was testing the one-line version of Ensemble’s value proposition on her, as well as sharing our focus of where we think we can create the most value for our clients. Distilling something as potentially big as a transformation down to a few words is hard, but I gave her our promise in these ten words:
‘We help ambitious executives in industrial environments
systemically improve production’
My friend’s reaction was positive, though she viewed ‘production’ in a narrower sense than we’d intended, feeling it referred only to the physical part of the process which handled the production of raw materials into finished goods. Perhaps we’ll have to revisit this statement. My hope, though, is that an executive will see the wider view when they go one level deeper into what it is we actually do. Let me unpack it and go a little further.
The ‘ambitious executives’ part was a no-brainer. If you want to get a result which outperforms, there’s no way to accomplish it without the commitment of an ambitious sponsoring executive. And my friend was certainly that.
Although I’ve done much work over the last twenty years in banking and retail, I’m most at ease in industrial environments—meaning places where you make a product. Those who work in mines, refineries and other plants within the domain of engineering have a deeper understanding of the need for tighter discipline in the planning and performance of work than, say, a relationship manager at a bank, or even a supermarket manager. And besides, by disposition and by training, I think and act like an engineer, so these folk speak my language and share at least a part of my worldview. Again, my friend agrees.
The ‘systemically’ part is because of our ‘systems thinking’ approach. No matter how hard you work the parts, the sum of their output is never what the system produces. And then we had the phrase ‘improve production’. We wanted to evoke the shop floor while still encapsulating the idea of all that the organisation sets out to produce.
To get to the point when you can claim to have ‘systemically improved production’, you’ll have had to develop a strategy, articulate a business case, secure the funding, design a solution, build or improve the product and its associated processes and services, market the offering and sell it to willing buyers—at a profit. All the people and business functions involved in that chain create a system that’s set up to produce something the market will value.
A whole of system change is a big chunk for any consultancy to attempt to bite off. What could Ensemble offer tier-one organisations that has the potential to radically improve their production as quickly as reasonable and possible? The one thing every such organisation shares is an asset.
In our context, an asset is anything capable of contributing a return on the value invested in it—whether at the scale of a business unit or a major piece of equipment. And what is the goal? For any rational investor, you would always be looking to maximise the net present value of your assets. Count all the cash spent on buying maintaining and operating the asset and pit that against the financial contribution the asset makes. Value the net cash outflows and inflows over the asset’s life, and compute that value in today’s money and you have the net present value (NPV) of the asset.
But here’s the rub. No enterprise has pockets so deep that they can invest in anything they want, let alone need. The extent to which funds are limited—and how organisations set rules to govern risk-weighted return on capital invested—creates a constraint.
Theory of Constraints (TOC) has become a significant and rich body of knowledge. I can’t think of an industry in which it hasn’t been applied. A customer, though, is seldom interested in taking a PhD in TOC to understand what it is before deciding to buy. In the first instance, they want to know what category of problem it is you’re going to address, as well as, importantly, what it is not.
Asset constraint management is the application of the full body of knowledge of TOC to the domain of asset management in industrial environments.
Of course, we’re not talking about asset management in the Wall Street sense of managing a portfolio of shares, bonds, cash and the like. But even in engineering, asset management covers topics as diverse as asset plans, asset strategies, reliability engineering, predictive maintenance, digital twinning, artificial intelligence and machine learning. The area of our focus is in the planning and performance of whatever work goes into maximising the asset’s value over its lifetime.
“It’s about choosing to do the right things
—then doing them right”
My friend said that people in her position want to believe there is hope of a better way of doing things. ‘Every executive,’ she said, ‘will tell you we spend money on the wrong projects. And we don’t do the projects we do choose as effectively as we should.’ This is exactly what Peter Drucker was getting at decades ago when he said, ‘Efficiency is doing things right; effectiveness is doing the right things.’
So how does a constraints perspective for asset management offer the hope these executives are seeking? It’s about choosing to do the right things—then also doing them right. We contend that by adopting TOC in the field of asset management, you will achieve business outcomes you otherwise would have thought were neither reasonable or possible.
What you think is ‘reasonable’ is determined by the experience, mental models and biases you bring to the table. When I first came across TOC I had exhausted every other means at my disposal of solving a really tough problem. Too much work, too few people to do it and a client who wasn’t interested in our ‘rock and a hard place’ story. My delight in learning that someone had invented a solution which broke new ground was tempered only by my anxiety as to whether or not we could incorporate the learnings into our ways of working fast enough to avert a catastrophic failure.
This shift in perspective that the solution offers is supported by physics, mathematics and statistics but, at the same time, it’s elementary in its common sense logic. Once you see what this shift enables, you will achieve business outcomes you would otherwise think were unreasonable.
And what do you think is ‘possible’? Possibility is about understanding that the world does not arrive with its challenges in neat straight lines. Even though you have set the strategic direction and studied a range of tactical responses, in order to deliver a result, you still need the energy of motivated people willing to put in the hard yards of engaging themselves and others to turn up consistently as their best selves. The quality and nature of the leadership that is brought to bear is critical, given the outsized outcomes on offer. Such change is definitely possible.
“The world does not arrive with its challenges in neat straight lines”
Many people stumble over the ‘theory’ part in Theory of Constraints. But as someone once told me, theory is the dinner jacket you take off when your car gets a puncture. One of the great joys I have in doing my work is seeing people’s lights turn on when they have the same epiphany as I had, and realise the simple but powerful idea behind TOC that makes it a genuine breakthrough.
There is a degree of comfort in knowing that the theory part of TOC is predicated on a falsifiable hypothesis—that all systems have constraints; otherwise, the output could be infinite. Furthermore, it is for all practical purposes an infinitely scalable solution, applying a single organising principle to the planning and performance of all work: projects, production, maintenance and distribution.
This is the ‘hope of a better way’ my friend was asking about. If you’re open to exploring the possibility, there are riches for the taking. Or as Leonard Cohen sang, ‘There is a crack in everything. That’s how the light gets in.’ You simply need to admit the possibility that your tough problem might have a solution you hadn’t considered. If you haven’t investigated TOC yet, it might be time to let it shine a light on your challenge.
In my next article, we’ll look at the four core domains where TOC and the Ensemble Way can make a difference to your Asset Constraint Management.
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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:
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[Background photo: ‘Blue light time’ by Max Larochelle on Unsplash]
“There is a crack in everything. That’s how the light gets in.”
―Leonard Cohen
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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.”
A medical device patient journey commonly depends on several healthcare professionals:
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.
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:
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?”
“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:
These personas clarify who performs each job and what support each person requires.
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:
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.
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.
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:
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.”
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:
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.
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.”
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.
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:
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.
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.
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.”
A typical medical device journey may include:
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.
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:
The answers reveal the true performance of the patient system.
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?”
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:
These differences affect whether patients enter the pathway, remain engaged and successfully adopt the solution.
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.
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:
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.
Stories create understanding, but investment decisions require structured evidence.
Patient observations and comments should be converted into outcome statements that identify:
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.”
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 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:
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.
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.
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We’ll only use your email address for this newsletter. No sales calls