1.
REMOVE
BEFORE FLIGHT
HOW TO IMPROVE MY
RELEASES’ LIFTOFF?

2.
TEXT

3.
TEXT

4.
WHAT COULD GO
WRONG?

5.
TEXT
1
2
5
6
9
8
3
4
ECMO
7

6.
TEXT
LINE INFECTIONS
▸ ICUs put 5m lines each year
▸ 4% become infected, causing blood-stream infections
▸ In the US only 80,000 people become infected each year
▸ 5%-20% are fatal!
▸ Survivors ‘enjoy’ extra week in hospital
▸ Can be dropped to almost zero

7.
REMOVE
BEFORE FLIGHT
MEANWHILE, IN ANOTHER
PART OF THE FOREST…

8.
CAN YOU IMAGINE JAVA RELEASING
A WORKAROUND, AND WITHIN ONE
WEEK ALL JAVA PROGRAMMERS
ADHERE?
AIRCRAFT MAKERS CAN. AND DO.

9.
A PILOT NOT FOLLOWING
CHECKLISTS WILL NOT BE
ALLOWED TO FLY THE AIRCRAFT

10.
PETER PRONOVOST
▸ Founded Quality and Safety group
in 2003
▸ Studied ICU infections since 2001
▸ Came up with a low tech tool that
saves 1,000s of lives

11.
PRONOVOST CHECKLIST

12.
PART I : MEASURE. DON’T FIGHT CULTURE.
▸ Asked nurses to record adherence to the steps
▸ In one month >30% doctors missed at least one step

13.
PART II : APPLY. HACK CULTURE WITH DATA
▸ Authorise nurses to stop doctors if they missed a step
▸ Over one year 10-day line infections dropped from 11%
to zero
▸ Outcome: reduction of 43 line-infections, 8 deaths, $2m
in costs
▸ All thanks to a simple checklist

14.
CULTURE AND PATIENT SAFETY
▸ The main barriers are the lack of collaboration and a
culture that is resistant to change.
▸ There is also a lack of systems integration.
You can't buy a functioning ICU or hospital like you buy a
finished car.

15.
CULTURE
▸ Doctors:
▸ Often over confident
▸ Believing things will go right
▸ Nurses:
▸ Typically have clear lines of authority for dealing with failure
▸ Often reluctant to question doctors
▸ Hospitals
▸ Typically don't pressure doctors for fear they will leave
▸ ……Sounds familiar?

16.
PRONOVOST CHECKLIST
▸ A simple, easy to follow, checklist
▸ Effective
▸ When followed, line infections are almost eliminated
▸ Hard to implement

17.
A PILOT NOT FOLLOWING
CHECKLISTS WILL NOT BE
ALLOWED TO FLY THE AIRCRAFT

18.
A DOCTOR NOT FOLLOWING
PRONOVOST CHECKLIST WILL NOT
BE ALLOWED TO THE ICU
…BUT HOW?!

19.
DEAR MANAGER,
WE’RE OUT OF SOAP

20.
TWO KINDS OF CHECKLISTS
DO-CONFIRMREAD-DO

21.
WHEN DOD MET CHECKLISTS
▸ Big Do-Confirm Checklist
▸ Really hard to implement

22.
THIS IS XP’S TEST-FIRST READ-DO CHECKLIST
▸ Red
▸ Green
▸ Refactor

23.
THIS IS SCRUM’S DAILY STANDUP READ-DO
▸ Answer three questions:
▸ What have I/we accomplished since last standup?
▸ What will I/we accomplish by our next standup?
▸ What is holding me/us back?
▸ Complete the round in less than 15 minutes

24.
WHEN TO RUN THE
CHECKLIST?

25.
PAUSE POINT
▸ Definition of Done - when accepting a story
▸ Red-Green-Refactor - when starting a development task
▸ Daily standup - every day at x:xx am
▸ Fix CI - whenever build breaks
▸ …

26.
TAKING THE DOD
TO THE GEMBA

27.
HOW TO GO ABOUT IT?
1. Set a DoD change group, including senior management, middle managers and
engineers
•Autonomize engineers to act; Get managers to help with resources
2. Find an aspect of DoD to improve
3. Identify good pause-point
4. Come up with a preliminary checklist
5. Start with measuring data. No change in behaviour required.
6. Autonomize the right people to follow and enact checklist
7. Experiment frequently with checklist steps
8. When mastered, go back to (2) - find a new problem
9. Repeat forever

28.
REAL LIFE EXAMPLE - MONITOR CUSTOMER LIVE SYSTEM
▸ Pause Point - Every day immediately following the daily standup
▸ Open customer monitoring dashboard
▸ Look for anomalies
▸ Urgent problem? Fix now
▸ Not urgent? Open defect for next sprint
▸ Not enough data? Add story to improve dashboard
▸ The team meets with manager and PO to prioritise defects and
dashboard changes

29.
PRACTICAL TIPS
▸ If it’s not painful, maybe it’s not worth investing the effort
▸ Make it fun, wherever possible
▸ Don’t push people (Newton’s 3rd Law)
▸ Autonimize people to experiment and change

30.
SUMMARY
▸ DoD = The Set of Standards
▸ Typically a big Do-Confirm Checklist
▸ Complement it by a collection of Read-Do Checklists
▸ If it’s not hard, it’s probably not done right
▸ It’s a journey, not a milestone. Think PDCA

31.
?

32.
LET’S PLAY HOW TO
MAKE A CHECKLIST

33.
WHAT IS
PAINFUL?

34.
WHO DO YOU WANT ON
THE APPLICATION TEAM?

35.
WHAT IS A GOOD
PAUSE POINT?

36.
WHAT DATA CAN
YOU COLLECT?

37.
WHAT READ-DO
CHECKLIST CAN YOU
MAKE? 3-8 STEPS

38.
ON A SCALE OF 1-10, HOW
LIKELY IS THIS CHECKLIST
TO WORK?

39.
ITERATION 2: WHAT READ-
DO CHECKLIST CAN YOU
MAKE? 3-8 STEPS

40.
WHAT WILL YOU DO
TOMORROW MORNING TO
TRY IT OUT?

41.
ON A PERSONAL NOTE
▸ My own workout checklist
▸ Sleep > 6 hours
▸ Prepare gear
▸ Set a workout plan
▸ No done checklist? No workout!

42.
THE END

43.
SOURCES
▸ https://en.wikipedia.org/wiki/Peter_Pronovost
▸ The Secret to Fighting Infections, LAURA LANDRO, WSJ March 2011
▸ The Checklist, Atul Gawande, The New Yorker, December 2007
▸ The Checklist Manifesto, Atul Gawande,
▸ Code The Unit Test First, eXtreme Programming website,
▸ The Scrum Guide,
▸ www.vox.com/2015/7/9/8905959/medical-harm-infection-
prevention

44.
IMAGES
▸ Remove before flight https://www.flickr.com/photos/8058853@N06/2502418431/
by Helgi Halldórsson
▸ BA38 crash https://upload.wikimedia.org/wikipedia/commons/5/5e/
BA38_Crash.jpg
https://en.wikipedia.org/wiki/File:Ice-Trent-800-Heat-Exchanger.PNG
▸ Pronovost Checklist http://www.vox.com/2015/7/9/8905959/medical-harm-
infection-prevention
▸ Recipe https://www.flickr.com/photos/maggiejane/4188717339/
▸ Before I die https://www.flickr.com/photos/javisanchezfotos/11690265575/
▸ Play / Rec / Pause Stop https://pixabay.com/en/buttons-stop-play-pause-
record-35531/