Startup energy

I attended, thanks to a series of encounters, an incredible pizza brainstorm sessions for startup founders during a CIC Venture Café in Cambridge, Massachusetts.

Thanks a lot to Erik Modahl (a charismatic human catalyst in the CIC) and Randall Bock (Chairman at and facilitator of the session) for letting me in.

Pizza startup brainstorm

The idea was that every venture founder would express his hottest challenge and gain insights from his fellow entrepreneurs, tips, or even find new partners to move forward.

What struck me was the level of energy, enthusiasm, positive thinking in the room. Ideas were popping everywhere really fast. Everybody was ready to lead a 10,000 people company in ten years.

I’m afraid my teams, in a large company R&D, even though they are pretty skilled and motivated, don’t reach that level of commitment and excitement. What lessons are there to be learned, what could be made better? I see two main angles: autonomy and speed.


The strength of the startup founders (particularly in the early stage, before they get funding) is that they decide everything. In one second, a pivot can be decided, an entire business model can change. No project approval committee to convince. No 8-level approval chain for internal workflows. No game-of-throne-like power struggles to understand and leverage.

Of course, I don’t think that deciding everything alone is a good thing – reviews are good; if you idea can’t resist some criticism, how will it withstand the harsh bite of reality? But large corporations die on spreading decisions (and incidentally accountability ) to too large groups of people. This is especially true in regulated industries, where the norms we abide by have a constant obsession for external reviews, checks and approvals – as if nobody could ever do anything useful in autonomy. This paves the way for a culture of unpowerment (un-empowerment).

What can we do to re-empower people?

Swarms consist of a large number of simple entities that have local interactions (including interactions with the environment). The result of the combination of simple behaviors (the microscopic behavior) is the emergence of complex behavior (the macroscopic behavior) and the ability to achieve significant result as a “team”.

I encourage everybody to read again Jürgen Apello’s Management 3.0 book. Autonomy and empowerment are not a hippie thing (even though I believe happiness in the workplace is a powerful driver, but that’s not the topic today): it’s about survival. The best-run complex systems are run by autonomously controlled units. Remember “The best architectures, requirements, and designs emerge from self-organizing teams.” in the agile manifesto? It’s true. It works. The inherent problem with approvals is that people higher in the hierarchy, whatever their talent and experience, have little time; they will always introduce delays, or worse, hasty bad decisions.

As a manager, what can I do concretely to decentralize decisions? It’s very simple. Every time somebody in my teams asks me for a decision on something they should decide alone, I try to refrain my natural impulse to tell them what I think, highlight the fact that it is inside their realm, that they are empowered to decide alone. The are welcomed to ask for advice when they feel unsure (and very often people find alone a solution to their problems by the mere fact of having to explain it clearly to somebody else), but not approval (which means to transfer the decision responsibility to their boss). This is not easy to do. I can’t say I always succeed, especially when I’m tired, stressed or in a hurry. Subordinates have a tendency to act as if you’re right, even when you’re not. It’s rewarding to decide – there must be something in the human psyche that makes power addictive. This tendency must be fought against or every organization will end up hierarchical.

This leaves a delicate question for managers: what do you do with your time when you stop stealing your subordinates’ natural areas of responsibility?

  • Help them. Be a ScrumMaster. Coach. Remove impediments.
  • Think. Now you have time, add value to the whole. Spot roadblocks. Have new ideas. Start new initiatives. Be creative.
  • Reclaim to your boss the areas of responsibility you should have been accountable for while you were micro-managing others.

All I see in this list is geared towards progress. By leaving room for others to grow and provide them the support they need, you naturally are inclined to grow yourself. Jürgen Apello has an excellent metaphor on people management: you should see yourself as a gardener. You choose bulbs and seeds. You design the macro landscape. You provide fertilizer and water, you remove pests and weeds. And then you let the plants grow. Just be sure to treat yourself as a plant in the garden too.



Once you have restored autonomy, half of the work required to speed up things is done. At least the decision process won’t be in the way anymore. So what about the second half?


Automation. Computer programs are fast. They work outside business hours. They don’t catch cold, get hit by a bus or change company overnight (okay, they have bugs and production issues, but these must get fixed). Aside from their benefits in cost and repeatability, I believe their prime benefit is to speed up the enterprise. So automate everything you need. Not only what’s related to the software factory  (continuous integration, automated testing), as I expect more or less everybody these days to be be on this path, but also administrative processes and quality-related records generation.

Speed up the others. On a personal level, I think everybody has a tremendous power in speeding ups its environment and business partners by being disciplined and having a sense of service. Get organized (for example, GTD works well for me). Always make sure you unlock any person waiting for you. When the job is represents a sizeable amount of work, consider splitting it in several iterations that you put to production (and take advantage of getting customer feedback as soon as version 1 is released, by the way).

Simplicity. Have a lean approach on every task – can you make it simpler, faster, cheaper? I heard Gregg Rodne Kirkpatrick say it the other day: “There is always a faster and cheaper way to do things.”

Startups have two special motivations to go fast:

  • Make money before you go bankrupt
  • Take that unique idea to the market before someone else does.

These two drivers are closely linked to survival and trigger very powerful reactions in venture founders’ heads. Large corporations have the second driver, only it’s not as powerful since they usually have several products and will survive if competitors do it first. And what about the first driver? I wonder if it’s possible to create inside larger corporations an environment mimicking startup drivers. Create a temporary group of people around an idea with a fixed budget (including internal staff cost). Name a leader enabled to take all kinds of decisions. When the money runs out, the group is disbanded. If the product gets to the market (or maybe a successful prototype), more funding can take the initiative to the next stage. I heard 3M is more or less organized this way. Has anyone experimented with it in the medical devices industry?

Highligts from BIOMEDevice Boston 2016 conference

I attended the BIOMEDevice conference on the 13th and 14th of April 2016. The conference was packed with suppliers of the medical device space, especially from Massuchussetts. Two conferences have especially rung a bell in my head, and I thought I might just drop my notes here so that everybody can get a feel of what was said:

  • Patient Privacy & Data Security in the Cloud Communication Age
  • Winning Over the Hospital Value Analysis Committees

BIOMEDevice 2016 conference hall

Patient Privacy & Data Security in the Cloud Communication Age

  • Our technology is advancing faster than we can protect it. How can we keep up with the cloud communication age and build sustainable data protection?
  • Understanding FDA’s evolving guidelines and standards to address cyber security
  • How is HIPAA playing an increasingly pervasive role in health data management?
  • Cloud-enabled utilities and solutions – what are the pros, cons, and security risks of storing data in the cloud?
  • Advances in safely transmitting data across various healthcare applications and protecting data from cyber attacks

Michael McNeil, Global Product & Security Services Officer, PHILIPS HEALTHCARE


Phillips has a HealthSuite IoT architecture based on AWS (EC2, S3, Glacier, Lambda, SNS)

They have a way to make sure data is not leaving a country’s borders where it’s forbidden.

Industry challenges:

  • Patient safety (ethical hackers have demonstrated threats)
  • Data integrity and availability – required by care
  • Legal and regulatory obligations
  • Protecting intellectual property – especially when expanding into emerging markets


Best practices:

  • Design security at every stage of development
  • Take advantage of well-known techniques (encryption, salting, rate limiting)
  • Train employees
  • Integrate security by design. Security built into the development process.
  • External security testing and assessment.


Medical device challenges:

  • Portable and mobile devices (storage medium encryption, hard to remove without tools)
  • Access to device and settings
  • Firewall controls
  • Malware controls (whitelist solutions take away the need for daily updates)


Avoid 3 deadly sins of medical device vulnerabilities

  • Uncontrolled distribution of passwords (fixed, default, hard-coded)
  • Failure to provide timely security software updates and patch management
  • Security vulnerability in off-the-shelf software designed to prevent unauthorized device or network access


The FDA has clearly stated that you don’t have to the entire re-submission process to address security updates (validation responsibility still applies though)


Establish a policy for providers and SOUPs (embed checkpoints in vendor selection, update the procurement process, establish monitoring criteria [frequency of scan and pen testing…]


Define a responsible disclosure of incidents process (they will happen!)



  • Continuous threat monitoring of the healthcare landscape is critical
  • Transparency, accountability and responsiveness must be ongoing features
  • Wider dialogue between medical device makers, hospitals, regulators and security professionals will advance innovation in security in the healthcare industry


Winning Over the Hospital Value Analysis Committees

  • Overview of the changing marketplace and how to position your product in this tight economic environment
  • USA vs. Europe – what are the hospitals looking for?
  • Important questions you should be able to answer
  • Looking at devices and assessing value – from a physician standpoint
  • Discussing value added services in products
  • Understanding the necessity of usability and how it can determine widespread adoption

David J. Dykeman, Attorney, GREENBERG TRAURIG, LLP

Eric T. Pierce, MD, PhD, Physician Director of Anesthesia Bioengineering, Supply & Technical Support, Department of Anesthesia, Critical Care & Pain Medicine, MASSACHUSETTS GENERAL HOSPITAL
Michael Fraai, Executive Director- Biomedical Engineering & Device Integration, BRIGHAM AND WOMEN’S HOSPITAL
David J. Berkowitz,
Vice President, Healthcare Insights and Analytics, ECRI INSTITUTE


Value Analysis Committees are now gatekeepers to inserting a technology into hospitals. Decisions are more and more based on financial factors, clinical benefits are not the paramount factor anymore.

Considerations they have

  • What do they do with former product if there is a replacement?
  • Cost – upfront and maintenance. TCO is king.
  • Clinical outcome – of backed by solid evidence.


Eric T Pierce, MD, PHD: how we select devices

Eric is involved in product selection for the Massachusetts General Hospital – especially for anesthesia

The selection process is always changing.

Value in Medical devices = Quality (outcome, safety, clinician satisfaction) / TCO

Traditionally, physicians were big drivers of device selection. They become less and less important.

When a product might be controversial, limited trials are set up.

For complex and expensive products, the process is the following:

  • An ad-hoc evaluation group is formed (physician director, bioengineers, clinician advocates, division leaders, frequent users)
  • Review all viable product options
  • Apply selection criteria (TCO, compatibility & continuity, ease of operation, serviceability, product support)
  • Narrow choice of 2 or 3 products
  • Focused trial of top choices in-service
  • Comparative financial analysis, purchasing folks negotiate
  • Review, recommendation, decision


The whole process takes weeks or month

Ease of operation criteria (very important):

  • Intuitive design
  • Simple interface
  • Clean-ability (they recently had a device which screen was damaged to cleaning solutions)
  • Battery life
  • Boot up time (because of emergencies). They time boot-up time.
  • Portability (big issue for them: portable devices get stolen)
  • Mounts


Winning over the value analysis committee – David J. Berkowitz, Vice President, Healthcare Insights and Analytics, ECRI INSTITUTE


We are moving from a volume-based healthcare system to a value-based healthcare system

The absence of evidence (as far as clinical benefits are concerned) is a showstopper


Michael Fraai, Executive Director- Biomedical Engineering & Device Integration, BRIGHAM AND WOMEN’S HOSPITAL

Network security is huge topic before devices are authorized into a hospital’s network.

They don’t buy a quote. They buy a solution to deliver safe & efficient care.

There is an awareness of real cost.

Factors in the TCO: purchase cost, backfill cost, training cost, device integration, software cost, warranty cost, implementation cost, parts, accessories.

It becomes more and more costly to integrate products into EHRs.


Panel discussion


Mistakes companies and salespeople make:

  • Adding too many features
  • Eliminating features that users do like
  • Not doing enough outcome research
  • Not understanding the user’s work environment (screens too smalls or difficult to read). Send your designers to the environment where the device will be used.
  • Introducing too many variable or deals
  • Not supporting intra-operability (ICE standards)
  • Not being the clients’ time and objectives
  • Not being environmentally responsible


There is an EPP (Environmentally Preferable Purchase) movement happening in the supply chain space


Advice for manufacturers:

  • How do you reduce downtime?
  • Think about helping institutions to compute the TCO
  • Analyze error logs and fix errors. Provide backup capabilities.
  • Have a real value dossier with all the stuff discussed above ready for the value committee.