Chapter 10

Services

IN THIS CHAPTER

check Using scrum in health care

check Strengthening schools

check Staying safe domestically and abroad

There are more than 9,000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.

— Clayton M. Christensen, The Innovator’s Prescription: A Disruptive Solution for Health Care

Scrum within service industries has enormous potential. We rely on health care, education, and public utilities to maintain and enhance our civilized society. Still, there is room for creating lean systems of cost savings and quality improvement. And in many cases, scrum is already being used.

Each sector has specific challenges. Unique sets of circumstances exist that need to be dealt with in a tailored way. Many of the outdated systems of development and maintenance were developed in simpler times. But as the world grows more complex, so does the need for innovative and flexible project frameworks. Scrum is ideal for dealing with new demands. We show you how and with what results.

Health Care and Scrum

Over the past few years, health care has been at the forefront of news. Affordable and accessible health care is often considered to be a basic tenet of a civilized society. Yet soaring costs, pressure to decrease development time without sacrificing quality, wasted spending, and increasing avoidable deaths have led to massive changes in the way Americans pay for and receive medical attention.

In 1970, health care spending in the United States was estimated to be $75 billion. In 2016 spending was $3.3 trillion or $10,348 per person and accounted for 17.9% of the Gross Domestic Product.

Added to this situation is a health care culture in which insurance reimbursements are increasingly linked to customer satisfaction. Health care technology has an expanded and important influence on clinical outcomes and patient satisfaction. New paradigms exist, and new methods for meeting their needs are required. It should come as no surprise that scrum is being used more frequently to address health care issues than ever before.

Some of the highest-priority challenges facing the health care industry are

In the following sections, we show you how scrum can help with the preceding issues. Scrum has been used within the health care environment with great success. It starts with administrative buy-in, followed by the implementation of scrum teams and their inherent roles. Then the process begins, following the road-map to value just like any other scrum project. Follow the stages we outline throughout this book, and watch the positive changes unfold.

In general, scrum brings the following benefits to the table:

Scrum is needed in the health care industry to help foster changes that support clinical decision-making within highly effective patient care and business administration. Health care struggles to evolve rapidly while also continuing to be compliant with the ever-changing demands of regulatory agencies.

Scrum has helped shorten development time for new administrative and clinical systems and increase quality and efficiency. The current health care environment is in flux between private and publicly funded care. Regulations and laws are being changed and refined. Therefore, a high degree of flexibility and transparency is necessary to survive in these turbulent waters.

Speed to market

Many of the diseases that our parents and grandparents suffered from as children are no longer daily concerns thanks to advances in sanitation and treatments, but new diseases are being discovered and exposed. Aggressive research and progress continue to find cures and prevent chronic and terminal illnesses. But health care professionals want to save more lives and save them faster.

Customer expectations regarding health care and the miracles of science are rising. Payers within the health care system are drilling down to find the best value in the medicines and treatments they’re buying.

Pharmaceutical companies are under constant pressure to devise new medicines to keep up with the stiff competition, yet they must do this within a cost-cutting and economizing environment. To compete and succeed, companies in this industry (as in every other industry discussed in this book) must be the fastest, most nimble, and most cost-effective.

Yet the pharmaceutical industry’s output has, on the whole, stayed flat. Most pharmaceutical organizations are tackling new situations and technological advances with the same project management frameworks they used in the 1940s. They’re surrounded by new ways of doing business, yet they’ve mostly stayed within traditional management mindsets.

Scrum can offer positive change in the following ways:

  • Every experiment begins with a hypothesis. In scrum, this hypothesis is the release goal.
  • In testing the hypothesis, premises are found to be true or false. Each premise is a sprint goal. The sprint backlog is broken into tasks and experiments needed to fully explore each premise. The definition of done for the sprint outlines the type of tasks and activities that must be conducted and accepted for a premise to be considered fully tested and explored.
  • At the end of each sprint, the team presents its findings to stakeholders, who ask questions and validate the team’s sprint conclusions. Stakeholders should include representatives of regulatory teams. If something was missed, the scrum team knows early and can conduct follow-up activities to address the feedback in the next sprint if it’s a priority.
  • After all premises have been validated, the hypothesis stands or is invalidated. Either way, the hypothesis reaches a releasable conclusion.
  • All the actions needed to test the hypothesis are the requirements of the product backlog and are prioritized accordingly.
  • For new products and improvements on old ones, scrum allows you to iterate quickly. The mantra “Fail fast, fail cheap” means that you can be as nimble as you like in trying new ideas and processes.
  • Self-organizing scrum teams allow developers to come up with the best research and solutions.
  • Customer, business, and regulatory involvement throughout the process means continual feedback and direction. For this reason, accountability is shared, and engagement rises.

Reduced mistakes, increased quality

Although current generations have the greatest technology and treatments ever known, we still have room to improve. Incredibly, mistakes during health care delivery in America are now the third-highest killer.

The kind of health care mistakes that cause harm can be such things as complex surgical complications that go unrecognized to more minor errors regarding the doses or types of medications given to patients.

No one knows the exact costs of health care errors because the coding system used to record death data fails to record items such as communication breakdowns, diagnostic errors, and poor judgment, all of which can cost lives. But we know that there are both human and economic costs associated with errors in care. Human deaths in the U.S. are estimated to be more than 300,000 per year and serious harm to be 10 times that high. The economic cost of medical errors can be estimated at $20.8 billion.

A report by the Journal of Health Care Finance estimates that these medical errors, if you include lost productivity in the workplace, may total up to $1 trillion annually. In many cases, these errors can result in a device or medicine getting banned forever on a very short notice, resulting in a complete loss to a company that has invested billions of dollars during the development cycle.

The causes of these errors may vary, but the quality assurance built into the scrum framework can ferret out problems and their solutions early. Scrum makes it easy to identify and deal with system inefficiencies, bottlenecks in work flow, communication breakdowns, and lack of timely feedback. The following are some ways scrum can help:

  • As communication increases, inefficiencies become visible. Scrum exposes these inefficiencies through daily scrums and sprint reviews; real solutions can be tried, tested, and adapted.
  • Although licensed physicians are the only people authorized to diagnose patients, self-organized teams (consisting of the entire staff) facilitate the necessary treatment, rather than the command-and-control system of the highest-ranking physician.
  • Feedback is rapid, and adjustments can be quickly implemented and retested.
  • As quality goes up, unnecessary risks and wasted costs go down.
  • As input from all members of staff and key groups is sought and used, buy-in increases, and morale improves. Buy-in or ownership is hugely valuable in health care, in which many people are overworked and burnout can be high.

Cost cutting

Those words alone are enough to pique the interest of any health care administrator. In a sense, every problem and solution we discuss in this chapter helps save costs. Avoidable illnesses and deaths, increased efficiency in care delivery and administrative flow, ease in following regulations, and pretty much anything else you can name can be improved to save costs.

remember Cost savings are a hallmark of scrum. Scrum not only helps you increase in speed to market, which accounts for a large part of the savings, but also streamlines processes, removes inefficiencies, and allows you to make better business decisions. The Center for American Progress stated in 2012, “Administrative costs in the U.S. health care system consume an estimated $361 billion annually — 14 percent of all health care expenditures in our nation. At least half of this spending is estimated to be wasteful.”

Consider savings in the context of unnecessary care costs. A 2012 study conducted by the Institute of Medicine estimates that in the United States we waste $750 billion annually on unnecessary health care. Causes include inefficient and unnecessary services, overpricing, excessive administration costs, and fraud.

Some of the ways scrum can help cut costs are

  • Sprint retrospectives: The sprint retrospectives in scrum routinely ask such questions as
    • What about our claims process is unnecessary?
    • How can we minimize repeat patient visits?
    • What additional steps can we take to reduce patient risks even further?
    • Where are the bottlenecks?
    • What if form XYZ were electronic?
    • What’s stopping us from increasing our daily claims processing rate by 20 or 50 percent?
  • Daily coordination of priorities: During daily scrums, such questions as these can be asked:
    • Is this necessary for this patient today?
    • What’s in the way of this patient’s going home well today?
    • How can we remove that obstacle?
  • Transparency and simplicity: With scrum, you want to maximize the amount of work not done, especially if it’s harmful. Reducing the number of early elective deliveries (37 to 39 weeks as opposed to 40), for example, would eliminate up to 500,000 neonatal intensive-care unit days.

Adhering to regulations

With the changes brought by the Affordable Care Act in 2010 came a flurry of new regulations. These regulations are in place to protect patients and health care providers, and each health care organization needs to find ways to comply. Implementing solutions to address new regulations can be challenging and even tedious, and having fewer resources to work with makes the process more daunting.

Here are some of the ways that scrum helps health care providers understand and abide by new regulations:

  • A product backlog can be created and prioritized by business value and risk mitigation. Then the scrum teams and the organization as a whole have the rationale to make business and resource decisions during complex times of regulation changes.
  • Previously, the technical and business sides of health care solutions may not have seen eye to eye; after all, their mandates were probably different. But as the business side is covered by a product owner and development teams are formed to design solutions, goals suddenly align. Scrum team roles are peer roles. Team members work together to facilitate the right environment for aligning goals and purpose, which is ideal for implementing changes to deal with regulations.
  • Self-organized teams define the best solutions. When new regulations are narrowed down and prioritized, it’s easier to pinpoint solutions and implement them quickly.
  • The evolving regulatory requirements can be built into the scrum team’s definition of done. This way, product owners and stakeholders can rest assured that they’ll be in line when audits and inspections take place.

Scrum isn’t an escape hatch for regulations. After all, regulations have the good of the patient in mind. Scrum is a tool for responding to changes by being tactically flexible while remaining strategically stable, thereby making sure that the goal — better health care — is achieved.

Medical device manufacturing and safety

Like the pharmaceutical industry, the medical device manufacturing industry operates within a highly competitive and cost-conscious environment. Many are beset by traditional project management mindsets. Up-front designing combined with late back-end testing means that defects are detected late and the costs of fixing them rise — assuming that the defects are detected before the product hits the market (see Chapter 4).

With scrum, you can

  • Build product testing into each iteration. Catch defects early, stamp them out, and implement better designs.
  • Co-locate designers with engineers so that they’re immediately accessible and can get real-time everyday feedback.
  • Add requirements as the project progresses. Many times, customers don’t know exactly what they want at the beginning. After the initial high-priority requirements have been developed, scrum allows customers to see a fuller picture.
  • Inspect and adapt constantly. Build only what’s most important, and test and garner feedback regularly and frequently.
  • Get daily signoff with the product owner on work done.
  • Receive feedback from stakeholders at regular sprint reviews. This feedback gets them involved throughout the development process.
  • Coordinate early and often when syncing software and hardware development.
  • Share the definition of done for both teams and include integration and testing throughout each sprint rather than at the end.

Education and Scrum

Throughout this book, we emphasize the fact that scrum can be used in a variety of industries — all of them, in fact. Scrum is a framework for developing products, not a software-specific tool.

Education is one such industry. Children are the future, as their children will be after them. Educating young people and ensuring that they have the ability to come up with creative, innovation solutions and decisions themselves should be the top priority of every culture.

Public education was created in a different landscape — that of basic education for workers. The need was simple, as the work world was simple. Today, however, complexity has grown exponentially, as have students’ choices of jobs and roles in the world.

Because of this change in the work landscape, education needs to prepare children to participate effectively in work. Many teachers are still trained to prepare and deliver material in the old way, but a better way exists.

Scrum in the classroom helps children adapt creatively and flexibly to change, prioritize projects and ideas, and come up with new solutions. Technology and media are changing so rapidly that the information that children receive is always in flux. With scrum, they learn how to turn change into an advantage.

Challenges in education

Education faces different challenges today than ever before. Curriculum is expanding in scope, underperforming students require more attention, and classroom sizes are increasing. Despite this appearance of chaos, progress can be made with scrum.

In many respects, teachers inherently use scrum, but they use terms that may not be known to those outside the profession, such as objectives, scaffolding, mini-lessons, modalities of learning, and reflection.

Teachers already set goals for each lesson. They use the standards as the goal and set objectives for the lesson, as some standards require multiple steps. These multiple steps are called scaffolding. Teachers break the lesson into iterations so that students can be successful and accomplish each necessary aspect. Along the way, they use formative and summative assessments to gauge and modify learning. Students and teachers alike reflect at the end of each lesson, as in a retrospective.

Next, teachers are trained to use collaborative learning models and do projects that engage students and get their buy-in.

Increasing curriculum scope

Curriculum requirements for teachers have been expanding for decades. More information must be covered, and teachers can be overwhelmed trying to keep up. These curriculum pressures come from four sources: school systems, governments, parents, and students.

Many topics and experiences used to be taught in the home by parents. School was for basics. Today, school systems cover subjects never before imagined in the classroom. A few that were introduced in the past decade are listed:

  • Bullying prevention
  • Antiharassment policies
  • Body-mass-index evaluation (obesity monitoring)
  • Financial literacy
  • Entrepreneurial skills development
  • Health and wellness programs

Nothing is wrong with these additional programs. In fact, they serve a great purpose. But teachers are being asked to include some of these topics, along with many other new ones, along with the old standards of reading, writing, and arithmetic. However, they’ve been given no more hours in the day for teaching and often work with limited resources and funding.

Students themselves arrive with a host of experiences and knowledge that would have been science fiction a few decades ago. They’re often computer-literate by their early years and have been exposed to adult themes and messages through television, films, and music. Although the teaching techniques we mention previously are inherently scrum, the spectrum of what’s being taught has grown. But the overarching goal of education remains the same: well-educated students.

Effective prioritization and inspection-and-adaptation methods are essential for administering this growing curriculum effectively. Teachers reprioritize as they carefully plan each day and empower students to be self-organizing and self-managing. Rather than follow a rigid plan outlined at the beginning of the year, they regularly conduct assessments and adjust their schedules, sometimes spending more time than planned on a subject to help a struggling class and sometimes spending less time than planned when a class understands a concept faster than expected.

Teachers are also recognizing the value of refactoring. In the old days, you took a test, you got a grade, and that was it. As educators have learned from experience, adaptations have been made to allow students to learn from their mistakes and be rewarded for their learning. Continual-feedback loops allow for learning, followed by an assessment (pretest or quiz), with feedback and more learning followed by the final assessment. The grade isn’t the only goal. Students are starting to understand and appreciate what they learn by using these same events as used in scrum.

Moving low-performing students upward

Teachers are hugely instrumental in moving students through learning blocks. Sometimes, however, teachers work from a structured curriculum that requires them to move on with new topics and subjects even though not all their students may have full comprehension. Although they may want to spend more valuable one-on-one time with each student, they simply can’t afford the time without preventing the overall curriculum from moving forward.

Therefore, the individual attention needed to help low- or moderate-scoring students sometimes isn’t available due to lack of time. Teachers need to keep progressing in their curriculum. Large class sizes can add to this conundrum.

As a result, low-performing students arrive in the next year’s class without fully understanding the previous year’s material, or they’re held back and taught the same material again without new learning techniques. Evaluations are done, but teaching doesn’t necessarily circle back to weaker areas of understanding.

Success in elevating individual students comes through collaboration among schools, teachers, parents, and students. If the scrum framework were applied for each student, with team members consisting of such participants as the teacher, the student, the counselor, a school administrator, and a tutor, this team could set iterative goals leading to an end goal, with regular feedback loops, all the while inspecting and adapting progress and the process to fit the student’s needs.

Increasing student-to-teacher ratios

Classes are getting bigger, and individual teacher-student attention is dropping. It’s a tall order to manage an entire class and the increasing curriculum and to provide student- and subject-specific teaching.

remember Teachers spend time building relationships, modifying a lesson, executing lessons, and helping students one on one. Finding time is the most important challenge of education. As funding decreases, but teaching methods and systems stay the same, it’s inevitable that education in the classroom will suffer. Scrum can help leverage teachers’ time and increase adaptability.

Scrum in the classroom

Scrum works in education like anywhere else. As scrum is based on goals and vision, setting focused learning goals allows students to adapt their learning styles to their speed of learning. By focusing on one learning goal at a time, students can master each subject and level before moving on. With scrum, teachers can emphasize high-priority learning items that students focus on.

Scrum remains effective in large classes because smaller scrum teams can be formed for projects. Within limits based on the ages and natures of individual groups of students, these teams can be self-organizing and self-directed to reach educational goals.

Inspection and adaptation work remarkably well in learning environments. Studies have shown that students who have lesson plans to adapt to and can work specific areas in which they struggle achieve better comprehension. Iterative teaching models have been introduced to the classroom with remarkable results in the following ways:

  • The teacher outlines the unit or project for all the students, and groups are formed (sprint planning).
  • The teacher executes daily teaching and guides group work-learning tasks, setting a time goal too (sprint).
  • The student and teacher assess student performance at the end of the timebox (sprint review).
  • If students perform above a preset cutoff level, they move to new material. If they perform below this level, a sprint retrospective is conducted.
  • Using feedback received at the sprint review, problem topics for each student are identified.
  • New teams are formed to maximize the teacher’s ability to help students by leveraging the challenges that each student is facing. These teams work together in increasing their understanding of the topic.
  • Material for these new groups is revised (product backlog refinement). Students come up with ideas about ways to better learn the subject material.
  • Another sprint is run.
  • Student performance is assessed.

This process is repeated, incrementally improving student performance.

In studies, student performance showed significant improvement. Students also made fewer mistakes, and had more confidence, and spent less time figuring out the problems.

Student scrum teams don’t have to be shifted; they can be kept stable. That way, cross-functional teams can be created, made up of students who have higher skills in some areas than others. Subsequent sprints use the same techniques as in pair programming and shadowing. By learning from other students, each student gains new skills, and advanced students expand their skill sets.

State and national standards dictate certain requirements for demonstrating mastery of subjects (that is, the definition of done), but each school or teacher can enhance the state or national definition of done to suit specific circumstances. What students learn and how they show that they’ve learned it are vital elements of the overall success of the sprint. Success will vary according to the situation, but the definition of done should be made clear to everyone, especially the students.

An example approach using scrum

How does the scrum-in-the-classroom concept work?

Kids love it. They become active participants with the whiteboards and sticky notes and the responsibility of making sure that each bit is in its proper place.

Following is how one teacher approaches scrum in the classroom:

  1. Set up a project of one to five days’ duration.

    This project is effectively a sprint. The teacher has the original plan but gets class buy-in through listing requirements. If the project is to understand the periodic table of the elements, for example, requirements could be sections of the table. Tasks might be the individual elements themselves.

  2. Scrum teams of students are formed, and team members decide who fills the scrum roles.

    These teams have a high degree of autonomy.

  3. A project backlog is created, often using a task board.

    The kids write down the requirements. The teacher serves as a scrum master and keeps everyone focused.

  4. Sticky notes on a whiteboard, wall, or blackboard are used to get children involved with ordering and prioritizing the requirements.

    Children love the sense of accomplishment that comes from seeing things move from the to-do stage to the doing stage to the done stage.

  5. Each project session begins with a daily scrum.

    The students are using scrum language, such as daily scrums, scrum master, and sprint reviews.

  6. At the end of each sprint, both the review and retrospective are conducted.

    Buy-in increases, and when appropriate, the students can contribute to goals for new projects.

Children enjoy the hands-on process and progress. They quickly see progress and are amazingly flexible in adapting. In short, kids naturally think in terms of the iterative process (see Chapter 1). Scrum is just a formalized way of dealing with natural brain wiring.

eduScrum

In Alphen aan de Rijn in the Netherlands, scrum is being used in a high school and secondary educational college. The program is called eduScrum, and educators who use it are experiencing amazing results.

Teachers and students use scrum in all subjects, forming scrum teams with all the roles intact. Three teacher scrum masters lead the charge, each facilitating the process in his or her class. The scrum masters also conduct daily scrums on the projects, as well as sprint reviews and retrospectives.

The school collected data on the results of this process with 230 students, ranging in age from 12 to 17. The results were impressive. In the Netherlands, test scores fall in a range of 1 to 10. A score of 5.5 is fine, but students strive for 6.7 or better. The students who participated in scrum teams consistently outperformed those who didn’t by 0.8 to 1.7 points — significant increases in terms of percentages.

Half the students said that they understood the subject material better, had more fun (hugely important for learning), could work harder and faster, and felt that they were learning in a smarter way.

Teachers also noticed greater engagement from their students and a more positive experience. Interestingly, corporations and organizations often report improved employee morale when they incorporate scrum.

tip An interesting side effect of scrum in schools was that the students reported just plain having more fun with classes and learning. This made them more eager to go to school and participate. And those shy, quiet types? They flourished as their skills and contributions were noticed in the reviews and retrospectives.

The team atmosphere also improved. Well over half the students learned to cooperate better and developed trust in their team members. They were open to giving and receiving feedback, and teachers noticed a more relaxed atmosphere.

Blueprint

Blueprint High School in Chandler, Arizona, is a not-for-profit organization that creates and implements special-education options. Leaders at the school decided that having a high school diploma wasn’t enough to prepare students for the twenty-first century. Students also needed skills in collaboration, creativity, accountability, critical thinking, and teamwork. Interestingly, scrum naturally fosters all these qualities.

Blueprint’s scrum roles were flexible based on the individual team context. Sometimes, the teacher was the product owner or scrum master; at other times, students took on these roles. As team members matured and garnered more experience, they automatically took over the role of product owner. The teachers simply identified the type of projects to be completed; then the students took over by developing their own goals, implementation, and reviews. Collaboration and teamwork skills took off.

The success of scrum in the high school led Blueprint to spread the idea into its elementary school with similar results. Although Blueprint didn’t conduct the type of quantitative study that eduScrum did, it experienced many positive anecdotal outcomes, including greater student engagement, more fun, greater empathy, independent thinking, and a more positive educational experience. One teacher said that her kids would even come in if they were ill because they didn’t want to miss a single day of school, which is wholehearted buy-in from students.

Military and Law Enforcement

Many agile and scrum experts appreciate Agile Principles and the scrum framework because of their experience in the military. Military organizations are mistakenly perceived to value strong centralized decision-making. Military strategists, however, have long known that centralized decision-making leads to defeat on the battlefield. A commander can’t possibly see all parts of the battlefield or communicate fast enough to understand a chaotic, rapidly changing situation or exploit fleeting opportunities. Wise commanders understand that they must empower those at all levels to make timely decisions.

In 1871, German military strategist Helmuth von Moltke (the Elder) sagely observed, “No battle plan survives contact with the enemy.” Today, his approach to decentralized decision-making is known to the military as Mission Command.

The doctrine of Mission Command allows leaders to make agile decisions and adapt under conditions of uncertainty. The principles are practiced by most Western military organizations, including the U.S. Marine Corps and the U.S. Army. The U.S. Army operates the Mission Command Center of Excellence to train leaders in the methods of decentralized decision-making.

Traditional military organizations have huge command-and-control structures. More military leaders are seeing that all command and control may not be the ideal approach after all, however.

In 2007, General David Petraeus enabled small, cross-functional teams to make agile decisions that exemplified the counterinsurgency on the ground in Baghdad. “Security of the population, especially in Baghdad, and in partnership with the Iraqi security forces, will be the focus of the military effort,” Petraeus said.

Special operations forces, also called special forces, are uniquely trained to be adaptable, self-reliant, and able to operate in uncertainty. In the U.S., special forces refer to notable teams like the Green Berets and Navy Seals.

In many ways, agile teams are analogous to special-forces teams. Both types of teams are small, highly trained, highly professional, cohesive, and cross-functional. Special-forces teams are small and cross-functional, so they can adapt to situations that arise. Cross-functionality means that every member of the team can do more than one thing; ideally, everyone on the team can do every skill necessary.

Like agile teams, special-forces teams are stable and long-lived. Through hard-earned experience, their members know how to work together and trust one another, and they pitch in to do whatever is needed to accomplish the mission. That mission may require fluency in a foreign language, building relationships with local villagers, or even skilled use of deadly force if necessary. The mission may call for any combination of those things, yet carrying out the mission may involve something completely different. Special-forces teams know how to learn and adapt.

Another similarity is that both agile and special-forces teams create a sense of mutual accountability. In high-stakes situations, whether in business or on the battlefield, the desire to not let down a team member is more important than any deadline.

Like scrum sprints, missions for military teams are normally broken down to be accomplished quickly, within weeks at the longest. Longer missions wear out soldiers, deplete supplies, and require significant ongoing support. You find an exponential correlation between the length of a mission and the cost and rate of failure. Short missions provide better focus, team morale, and success.

One of many examples in which a military commander succeeded by changing his command-and-control approach is Admiral Nelson at Trafalgar. Instead of requiring strict adherence to signal flags hoisted on his flagship, Nelson delegated substantial authority to ship captains, saying, “In case signals can neither be seen or perfectly understood, no captain can do very wrong if he places his ship alongside that of the enemy.”