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Pairing in History

I was reminded of a post I made after visiting  Bletchley Park and the National Museum of Computing some years ago and realised it needed moving to my own blog. So here it is:

While visiting  Bletchley Park and the National Museum of Computing  I discovered some examples in history when pairing really worked.

The first example was in the “tunny room”. Messages from the German high command were transcribed here during World War II for processing in the decryption machines, after being intercepted at Knockholt. When a transmission was received on the incoming telegraph, it was transcribed onto tape feed by two operatives so that it could be fed into the machine. As the tour guide pointed out

“two girls were used for this, with the assumption being no two girls will make the same mistake”.

Reducing mistakes is one of the key benefits of pairing in software development teams, and prevents defects appearing later down stream. In the case of the Bletchley workers, the letters they were typing would have been Lorenzo code, a raw ciphertext received via headphones, so a misplaced letter could have thrown the decryption out completely, causing delays and misinformation.

The second pairing example was in the post war section of the museum, home to a restoration project for a 1950s punch card archiving system. The room, which does the work that a database might do today, is full of oily, complicated looking machinery. The first machine was the puncher. This was used to mark the cards with the data that needed storing – in the example at the museum, these were orders for a sales team. The pairing occurred here, at the point of data entry. Two operatives would have slightly different machines; one would punch a hole slightly above the number mark on the card, and one slightly below. A valid mark was therefore represented by an oval shape where the two punches intersected. A second machine, the verifier, was then used to ensure there were no errors on the cards. It detected single holes in the punch cards and flagged these as errors by outputting the values on a pink card. Cards that only had oval holes went onto the next stage. We still use pink cards on our Kanban wall to represent defects.

In this example the pairing was inherently built into the system through the mechanics of the machines involved and must have prevented a great deal of erroneous data getting through.

So, if pairing was so useful in during the war, and built into machines in the 50s, why isn’t it the de facto standard for software development today? Why hasn’t it simply grown in popularity since the 50s? I’d not heard of pair programming until I’d been working in the industry for 2 years, even having been at university for 3. There are many benefits to pairing in addition to the reduced defect rate, yet the practise doesn’t seem to have stuck around.

There does seem to be a resurgence of interest in pairing as agile software development gathers pace and I’m sure most of the luminaries of the agile world have been doing it for years. But why hasn’t it always been wide-spread?

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F1 and Paediatric Intensive Care

A joint presentation between Paul Shannon (7Digital, Agile Staffordshire) and Dr. Harriet Shannon (Great Ormond Street Children’s Hospital Institute of Child Health) on findings from research by KEN R. CATCHPOLE PhD, MARC R. DE LEVAL MD, ANGUS MCEWAN FRCA, NICK PIGOTT Frcpch, MARTIN J. ELLIOTT MD, FRCS, ANNETTE MCQUILLAN BSc, CAROL MACDONALD BSc and ALLAN J. GOLDMAN.

The research focussed on reducing the amount of time to transport patients from the operating theatre to intensive care, and how this relates to Agile teams. The intensive care team wanted to improve patient recovery and manage risk by removing bottlenecks and defining responsibilities for emergency situations.

Intensive care teams attended sessions with an F1 pit crew to understand how their roles, responsibilities, communication techniques and safeguards could help meet their goals. Parallels can be draw between these aspects of the F1 team, the intensive care team and agile teams; similar roles (Chief Engineer, Head Surgeon, Product Owner) and safeguards (Replacement wheel guns, spare heart monitors, automated acceptance tests) are two of the key successes. Conversely, some of the more successful practices adopted by the intensive care team (implementing more detailed processes rather than relying on communication and collaboration) conflict with current agile thinking.

This has been presented at both Agile Staffordshire in June 2011 and XP Day in November 2011.

Paper

It appears Wiley Online are publishing the article that our presentation is based on for free so it is available for viewing as a PDF or HTML without the need to sign up:

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality

Presentation

I used Prezi to create a simple presentation for the session – split into two distinct parts with the presentation of research first followed by some key questions and talking points for a discussion. The prezi is available via the prezi web site.

Content

Harriet had already written up a large amount of her part of the presentation so I thought I’d convert it into a blog post so that those that missed either of the sessions don’t have to miss out.

Introduction

Great Ormond Street Children’s Hospital (GOSH) is an international centre of excellence in child healthcare and treats 175,000 children per year, in over 50 different specialities. Together with its research partner, the UCL Institute of Child Health it forms the only academic biomedical research centre specialising in paediatrics in the UK.

One of these specialities is heart surgery. GOSH sees about 500 cases per year, whether it’s heart transplant, re-wiring blood vessels, patching up holes etc. providing cardiac support.

Patients undergo heart surgery in the operating theatre in the north wing of the hospital. They are then transferred onto a trolley and taken along some corridors and up in some lifts, before reaching the intensive care unit to start their recovery.

What Are We Transferring?

The patient, all the technology and support (ventilators, monitoring lines, infusions of medicines). Also, knowledge about the patient, about any complications found during the operation, any specific instructions for the medical staff on the ICU – it is this combination of tasks that makes the process susceptible to error, at a time when the patient is most vulnerable.

Aims of the Study

The primary aim of the study was to improve safety and quality of care by observing the Formula 1 pitstop crew.

Why F1?

The pit crews are a multi-professional team coming together to perform a complex task (change tyres and refuel). There are huge time pressures involved (a pitstop should take less than 7 seconds). Errors cannot be tolerated and often result in disastrous consequences.

This fits in with the handover team as they are also multi-professional: surgeon, medics, nurses. The time pressue is of paramount importance with a maximum of 15 minutes for each handover. Even small erros can have larger consequences as the patient’s health is at risk.

The F1 Team Task

  • The “Lollipop man” has overall control of the pitstop
  • The car goes up on the jack
  • Wheel nuts come off, followed by the old wheel
  • New wheel goes on and secured with the new wheel nut
  • Driver’s visor is cleaned
  • The car is fuelled
  • Car is lowered from the jack
  • Lollipop man gives the all clear to go

Changes Adopted

  • LEADERSHIP – previously is was unclear who was in charge, now the anaesthetist took overall charge while the surgeon moved around to gain an awareness and overview of the situation.
  • TASK SEQUENCE – a clear rhythm and order of events was adopted whereas previously tasks were inconsistent and non-sequential. The main tasks were broken into three distinct areas:
    • Equipment and Technology
    • Information handover
    • Discussion and plan
  • TASK ALLOCATION – everybody now knows what they are doing whereas it was previously informal and erratic. Everyone is responsible for a single, well-defined task.
  • COMMUNICATION – only one person speaks at a time, and during information hand over, this is in a specific order. The group is given equality so that nurses can easily communicate with consultant or surgeons, spotting mistakes sooner – previously imposed hierarchies meant people in different roles did not communicate.
  • TRAINING – the clinical team ensured that their process could be easily taught so that the high turn over of staff could be combated with efficient and thorough training. The training is now done in 30 minutes and a laminated check-list is kept with every patient.

Results of Adopting Changes

  • Technical errors were found to be down by 1 third
  • Handover omissions were halved
  • Duration of handover decreased
  • Teamwork was perceived as the single most significant factor

Discussion

How does this apply the agile software development teams? Following the presentation session at both Agile Staffordshire and XP Day we had a short discussion. It appears that there are similar roles, situations and practices in software development that align with the findings. In the interests of brevity I thought I’d write-up the findings from the discussion in a separate post – I create a link here once published.