Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.

Remove before flight #APIL17

88 visualizaciones

Publicado el

What can we learn from the standards of aerospace industries that can help us improve our Definition of Done?
Quite a lot, as it turns.
Based on learning from The Checklist Manifesto (Atul Gawande) and research by Peter Pronovost on patient safety, in this talk I make an analogy from real life ICU stories to software teams.
And finally also provide a short guide to help you bring your DoD to higher standards, one notch at a time

Publicado en: Software
  • Inicia sesión para ver los comentarios

Remove before flight #APIL17

  1. 1. REMOVE BEFORE FLIGHT HOW TO IMPROVE MY RELEASES’ LIFTOFF?
  2. 2. TEXT
  3. 3. TEXT
  4. 4. WHAT COULD GO WRONG?
  5. 5. TEXT 1 2 5 6 9 8 3 4 ECMO 7
  6. 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. 7. REMOVE BEFORE FLIGHT MEANWHILE, IN ANOTHER PART OF THE FOREST…
  8. 8. CAN YOU IMAGINE JAVA RELEASING A WORKAROUND, AND WITHIN ONE WEEK ALL JAVA PROGRAMMERS ADHERE? AIRCRAFT MAKERS CAN. AND DO.
  9. 9. A PILOT NOT FOLLOWING CHECKLISTS WILL NOT BE ALLOWED TO FLY THE AIRCRAFT
  10. 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. 11. PRONOVOST CHECKLIST
  12. 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. 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. 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. 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. 16. PRONOVOST CHECKLIST ▸ A simple, easy to follow, checklist ▸ Effective ▸ When followed, line infections are almost eliminated ▸ Hard to implement
  17. 17. A PILOT NOT FOLLOWING CHECKLISTS WILL NOT BE ALLOWED TO FLY THE AIRCRAFT
  18. 18. A DOCTOR NOT FOLLOWING PRONOVOST CHECKLIST WILL NOT BE ALLOWED TO THE ICU …BUT HOW?!
  19. 19. DEAR MANAGER, WE’RE OUT OF SOAP
  20. 20. TWO KINDS OF CHECKLISTS DO-CONFIRMREAD-DO
  21. 21. WHEN DOD MET CHECKLISTS ▸ Big Do-Confirm Checklist ▸ Really hard to implement
  22. 22. THIS IS XP’S TEST-FIRST READ-DO CHECKLIST ▸ Red ▸ Green ▸ Refactor
  23. 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. 24. WHEN TO RUN THE CHECKLIST?
  25. 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. 26. TAKING THE DOD TO THE GEMBA
  27. 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. 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. 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. 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. 31. ?
  32. 32. LET’S PLAY HOW TO MAKE A CHECKLIST
  33. 33. WHAT IS PAINFUL?
  34. 34. WHO DO YOU WANT ON THE APPLICATION TEAM?
  35. 35. WHAT IS A GOOD PAUSE POINT?
  36. 36. WHAT DATA CAN YOU COLLECT?
  37. 37. WHAT READ-DO CHECKLIST CAN YOU MAKE? 3-8 STEPS
  38. 38. ON A SCALE OF 1-10, HOW LIKELY IS THIS CHECKLIST TO WORK?
  39. 39. ITERATION 2: WHAT READ- DO CHECKLIST CAN YOU MAKE? 3-8 STEPS
  40. 40. WHAT WILL YOU DO TOMORROW MORNING TO TRY IT OUT?
  41. 41. ON A PERSONAL NOTE ▸ My own workout checklist ▸ Sleep > 6 hours ▸ Prepare gear ▸ Set a workout plan ▸ No done checklist? No workout!
  42. 42. THE END
  43. 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. 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/

×