Fractional CTO for healthcare and hospitality SMEs.
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Two weeks. One product family. Two current-state maps. A board packet of about eight to twelve pages. Learn stops when the sponsor has seen the real operation, the baseline you could actually measure, and three constraints. The future state is a later step.
Companies keep a process on paper. The dining room, the intake desk, the deploy checklist. The floor runs a different one. The point of these two weeks is to capture the current state of the technology organization as it operates, before anyone recommends a platform.
A three-day conference-room mapping workshop, the kind Karen Martin and Mike Osterling describe, includes designing the future state. A fractional CTO who does not already work in the stream cannot get the real process from that room. The ten days below stretch the same two walks into shadowing. Future-state design stays in Strategy.
Run Monday to Friday for two weeks. The sponsor owns access, shows up on day 1 and day 10, and is the person who can put you next to a screen.
Map one product family. “The technology organization,” “patient care,” and “the hotel” mix triggers, so the times mean nothing. Martin and Osterling’s preparation splits patient care into a setting and then a modality, and splits service work by customer and job type. Pick the family that is highest volume, highest margin, most painful, or the one whose leader will sit through the briefing.
Healthcare charter. Established-patient office visit at one clinic, from the request for a slot to a payer decision on the claim. New patients, procedures, and referrals are out. If the business is imaging, use one modality from referral to a delivered report.
Hospitality charter. One property, OTA leisure stay, from reservation creation to a settled folio. Walk-ins are a different subprocess. Groups and banquet stay off this map. A published check-in study of a 55-room Prague property (Chalupa and Petricek) treats walk-in that way because the work is different.
Change stream, both. One representative change to the system that stream depends on. An EHR or interface change, or a PMS, POS, or channel-manager change. Walk it from production backward.
Before day 1 the sponsor sends the paper SOP, ninety days of incidents or vendor tickets, any deploy log, and either a denial report or an overbooking report. In a clinic, confirm how a contractor is allowed to stand next to a screen that shows patients. The HIPAA Security Rule’s safeguards for electronic protected health information are an access constraint on the shadowing. They belong on the map wherever that information moves.
Draw nothing on day 1. Days 2 through 5 are full shifts, or as close as the operation allows.
Day 1. Charter. Sit with the sponsor and the people who run the stream. In a clinic: the clinic manager and one person from scheduling, nursing, and billing. In a hotel: the general manager, front office, and one night auditor. Write the trigger, the first step, the last step, what is included, what is excluded, and the demand rate if they know it. Write what this engagement will not change. Read the SOP. Put it away.
Day 2. The front door. Healthcare: front desk and schedulers. Phone, portal, and fax referral. Watch insurance re-keying and slots booked then unwound. Hospitality: reservations and the channel manager. Watch a booking arrive from an OTA and whether it exists in the PMS. Time the gap from OTA confirmation to a PMS reservation.
Day 3. The core work. Healthcare: medical assistant and clinician for a session, then the inbox after the session. Time door-to-clinician, the encounter, and notes still open. Hospitality: check-in for a full arrival peak. Time guest-facing work separately from registration with no guest at the desk. Systems at check-in are the PMS, the payment gateway, and the locks. Stay into the next arrival if the room is not ready.
Day 4. The path that gates the customer or the money. Healthcare: revenue cycle. Charge capture, coding query, claim submit, denial, resubmit. Follow one real denial back to the note or the authorization. The Institute for Healthcare Improvement’s claim illustration is the shape: nine steps, 19 minutes of work, 28 days elapsed. Hospitality: housekeeping room status, because it gates the key, and one meal period from order to POS payment to folio post. Night audit if checkout is too thin. A charge that never hits the folio is a lost handoff.
Day 5. Production, without the pager. Read the last incidents. Sit one handover. Record what pages, what is a vendor ticket, and what is a workaround. Google’s SRE guidance on onboarding is to shadow on-call and read postmortems. Dropping a visitor in as primary on-call is the anti-pattern. In a hotel, ask about Saturday-night failure modes even if you are there on a weekday: locks, payments, channel manager, Wi-Fi, POS down.
John Shook’s order for a gemba walk is what, then why, then what if, then why not. “Why” before you have seen the work turns the walk into an argument. At every block:
At the front door: show the last request you could not complete on the first contact, and what you retype that was already captured somewhere else. When two systems disagree, which screen do you trust?
With the clinician, the server, or the cook: what did you work around in the last hour, and what is still open when the patient or the guest is gone?
With revenue cycle or night audit: what is the most common reason you send this back, and which code, rate, or posting rule do people “just know”?
With on-call: what woke someone up in the last month, how do you roll back, and when did you last do it?
Leave “what should this look like,” “which platform should you buy,” and “how would AI do this” unasked. A solution offered on the floor changes the work and teaches people to hide the workaround.
Day 6. One change, walked backward from production. Healthcare: a change that shipped in the last quarter, such as a schedule template, an interface, or an order set. Start at “it is in the live EHR” and walk back through verify, vendor or change board, test, build, review, and who asked. Hospitality: the same for one rate, menu, or interface. Start at “guests are on the new rate” or “the POS posts to the PMS.”
MinimumCD’s path is the list you are looking for: intake, refinement, build, review, test, security, staging, acceptance, approval, production, verification. In these companies many of those boxes are a person emailing a vendor. Write that down. It is the baseline.
Day 7. Metrics. You already know the blocks. Fill process time, lead time, work in progress, and the receiver’s percent complete and accurate. Pull denial rates or overbooking counts from the system, not from memory. Write the sample size. The Prague study timed 102 check-ins. You will have the arrivals you actually saw.
Day 8. Demand, in the caller’s words. Sit a shift with whoever answers. Log the opening sentence. Mark value demand (I need a visit, I want a late checkout) against failure demand (you never called me back, I have a confirmation and you do not, the room is not ready). Failure demand is John Seddon’s term: demand caused by a failure to do something, or to do it right, for the customer. If you only count the ticket types the organization invented, repeat contact looks like productive work.
Day 9. Draw. Two maps, 5 to 15 blocks each. The operation stream, and the change stream. A new block starts where work stops: a handoff, a pile, or a batch that is worked at set times. Draw rework as a loop. Put system names on the information arrows, and mark paper versus electronic. Mark the three worst waits and the three lowest percent-complete-and-accurate scores.
A 90-minute EventStorming session at the end of the day is optional, and only with people you already shadowed. Use it to put domain events in order and to surface two names for the same moment (“checked in” and “key made”). It does not produce process time or percent complete and accurate. It does not replace the walks. Domain storytelling is the same class of workshop. A second modeling session does not fit these ten days.
Day 10. Calculate, then brief for one hour. The sponsor is in the room. Report total lead time along the path the customer is waiting on. Parallel branches are not added together. Housekeeping and check-in meet at the key. Total process time. Activity ratio, which is total process time divided by total lead time. Rolled percent complete and accurate, which is the product of the block scores. Martin and Osterling’s slides show five “pretty good” handoffs multiplying to about 30 percent, and they treat 0 to 15 percent as a common current-state finding. Handoff count. Rework share. Three constraints, each with a number. The demand split. DORA numbers if a pipeline exists.
Say what you could not measure. Leave the paper SOP in a one-page appendix as the contrast. Recommend no tool.
Each block carries:
Under each map: total lead time, total process time, activity ratio, rolled percent complete and accurate, handoff count, rework share.
MinimumCD’s name for the activity ratio is flow efficiency. Their Phase 0 note is that teams are often shocked to find it under 15 percent. A busy team and a slow stream are compatible. The ratio is what you report, not a story about how hard people are working.
Publish these in separate boxes. Mixing them produces a number nobody can act on.
On the change stream, classify the work the way Kersten defines flow items: features, defects, risks, and debts. An “AI and DevOps” program that does not know this mix will fund features while the stream is full of defects, compliance work, and EHR or PMS debt.
Dominica DeGrandis’s five time thieves are worth tagging when you see them: too much work in progress, unknown dependencies, unplanned work, conflicting priorities, and neglected work. Write down the ones you watched. They are invisible on a roadmap.
The rules are the same. The industry changes who you stand next to and which artifact you follow.
In a clinic, follow a claim as well as a visit. IHI’s instruction is to map the process as it operates, and to walk a referral or a claim. NHS England’s QSIR guide adds a useful trick: walk the patient path in reverse once, end a process box when the person is waiting, and draw information flow above the path. The visit clock is clinic hours. The claim clock is calendar days. Say which clock each total uses.
In a hotel, follow a reservation that may not be in the PMS. Risks recorded in the Prague check-in study include overbook and walk-out, a third-party confirmation the hotel was never paid for, and a payment or lock failure. Also shadow the channel manager, housekeeping status, POS-to-folio, and night audit. Kitchen and POS matter when food is part of the folio, not as a tour of the restaurant.
The boxes are departments. A value stream is the activities that turn a request into a result, not the org chart. If the boxes are “IT,” “clinical,” and “finance,” there is nothing to time.
The map is the happy path. Include workarounds and rework. If every change takes a different path, agree the most common path and label it. A map with no loop back to coding, the vendor, or the payer is the SOP.
You interviewed managers only. Percent complete and accurate is answered by the person who receives the work. MinimumCD wants the people who build, test, operate, and approve in the room, because each one sees waits the others cannot.
The stream is too wide. More than about 15 blocks means you are drawing a procedure, or you chartered “the hotel.” Two maps of one service in ten days is the whole job.
You started at intake and never reached production. The long wait is often the approval, the environment, the vendor, or production verification.
You fixed tickets. Once you are the person closing them, people perform the official process for you. You are there to see the interrupt load.
You selected a tool. Martin and Osterling list this as a known way mapping fails: using the session as a work-design or tool-selection exercise. The action inside Learn is the briefing and the three constraints.
Assess receives the charter, the two maps, the summary line, the demand sample, the three constraints, and the list of what was not seen. It does not receive a vendor recommendation or a future-state design.
MinimumCD’s Phase 0 reason for doing this at all: a team with a three-week manual test cycle does not need deployment automation first. The map decides where the first investment goes.
The call is to decide whether this engagement fits. The answer can be no.