Clinically Agile: How Doctors in the UK Used Elements of Scrum and Scrum@Scale in Their COVID-19 Response
The United Kingdom has been hit particularly hard by COVID-19. For healthcare workers, the nature of this pandemic means they are dealing with complex, constantly changing conditions that affect their ability to treat patients and save lives.
“We adapted, did what seemed to be sensible at the time and maintained a high-quality emergency service throughout this period,” that is how Dr. Robert Macadam describes what he and the team of medical professionals he works with approached the height of the COVID crisis.
Dr. Macadam and his friend, Dr. David Raw, work at different hospital systems in the UK. They both implemented different aspects of Scrum and Scrum@Scale to better deal with the pandemic. Together, they reached out to Scrum Inc. to share their stories and success in the hopes what they did – and continue to do – may help other healthcare workers overcome some of the challenges of dealing with COVID-19.
“This Situation Was So Volatile”
Dr. Robert Macadam is the Clinical Director of General Surgery at St Helens and Knowsley NHS Trust, a group of teaching hospitals near Liverpool. He says that when stay-at-home orders went into effect, elective surgeries stopped “pretty much overnight.” Dr. Macadam and his team instantly switched gears to be able to “upskill and do some of the emergency airway procedures we thought were going to be necessary.”
Additionally, while the number of general surgery patients went down, Dr. Macadam points out that the patients they were treating were far sicker. “That's because they were staying at home longer and really didn't want to come into the hospital.”
Complicating this situation yet further was the impact the pandemic was having on the availability of the medical staff itself. Anyone showing flu-like symptoms, or who may have been exposed to COVID-19 had to be sent home and self-quarantine for two weeks. This created a significant staffing problem. “At any time we lost 25-30% of our workforce,” explains Dr. Macadam, adding “We still had to staff a 24/7 emergency service and provide high-quality care for our admitted patients.”
“This Is What We Did”
Dr. Macadam didn’t tell his co-workers and staff they were suddenly implementing Scrum. There was no need to. The situation required constant adaptation and clear communication. Everyone knew it.
The first Scrum element Dr. Macadam used was the Daily Scrum. At 8:15 every morning, Dr. Macadam, along with the senior nurse and representatives from ward management and other staff would meet to reassess the situation and set up a plan for the day. “We had a set agenda that started with who was still off sick or had reported symptoms in the previous 24 hours.” The office whiteboard was filled with a grid showing names, who were available that day, who was quarantined, and their expected return date.
Together, they established the day's rotation, for both AM and PM shifts for the 55 members of the general surgery staff. All within 15 minutes.
By 8:30 am, every member of the medical staff received an electronic spreadsheet that included names and contact numbers for everyone working that day.
The next principle of Scrum Dr. Macadam and his employed was the concept of self-organizing teams.
The medical field is defined by silos. Positive patient outcomes rely on those with specialized skillsets and knowledge working in concert to provide effective care. In the UK, consultants (the equivalent of attending physicians in the US) are paired with less senior doctors, nurses, and others to create a full complement.
Viruses, however, hit indiscriminately. So the daily staffing shortage Dr. Macadam and his colleagues were dealing with could leave giant holes in well-established teams.
The decision was made to create two four-consultant teams with pooled junior doctor support, a red team, and a blue team. Those on the schedule that shift would decide themselves who undertook the various roles within the red and blue teams and ensure each team had the needed specialists. “Everybody bought into it,” says Dr. Macadam, “It really, really worked.”
“It Could Have Been Straight Out of the Scrum Playbook”
Dr. Macadam says the results of implementing this scaled-down version of Scrum were significant. This new system, with elements of Scrum at its core, was both effective and empowering. “We were a group of clinicians pulling in the same direction.”
Despite the chronic and unpredictable staff shortage, they were able to not only handle their caseload, “we were able to donate junior staff to harder-pressed services.”
And by making important information transparent they were able to create efficiencies in the system that helped improve patient outcomes. Take that spreadsheet with the daily staffing list and contact information. Dr. Macadam notes that once that became available, “there were no instances of desperate nursing staff trying to identify a doctor to review a patient.”
As time went on, and the improvements continued, their confidence in this new system grew. Dr. Macadam and his colleagues were able to resist the push to create overly detailed plans covering timespans longer that the pandemic would allow. “We knew we were going to get thrown a curveball sooner rather than later,” he states, “what’s that Mike Tyson quote? Everybody’s got a plan until they get punched in the face.”
Dr. Macadam and his team were and are still able to plan their COVID-19 response. By adopting an Agile mindset, they can also respond and adapt quickly to the change they know will come. To avoid getting knocked out by that punch. And to continually help others heal even in the midst of a pandemic.
Dr. David Raw and Scrum@Scale
Dr. David Raw implemented certain elements of Scrum@Scale to adapt and overcome the significant challenges he and his colleagues were facing. The first was to surface the problems and impediments that were standing in the way of care. “In my leadership role, I would attend three meetings every morning,” he states, each was short and focused on what was happening on the ‘shop floors’ of the hospital. “we’d go over issues with equipment, resources, patient admissions, staffing, and so on.”
He recorded all the impediments identified at these meetings in a notebook he has to this day. Many entries would soon be replicated as a note on an online Trello board so they would be visible to all. And progress towards removing each impediment could be tracked.
In short, Dr. Raw and his team set up a functioning Scrum Master Cycle and Executive Action Team.
At 10:00 am Dr. Raw had a standing meeting with other senior leaders. “it was a very easy way in which I could access the top tiers of the organization without having to go through the usual barriers and channels.” They resolved all the impediments they could. If needed, they had a direct channel to the CEO to ensure impediment removal was efficient.
This enabled the front-line medical staff to focus all their effort and attention on where it should be – patient care.
Clear Vision and Communication
The use of online information-sharing tools like Trello allowed the anesthesiology team to ensure effective asynchronous communication around the clock. “The dissemination of this information was key because we'd already gone into an emergency roster. So, some people were working nights, other people were on days, and yet we were still able to keep everyone informed and engaged with the preparations.”
This allowed the doctors, nurses, and other staff to fully understand workflows, patient journeys through departments, and more. All this helped ensure protocols were not just understood but followed.
Minimum Viable Bureaucracy
Every healthcare setting is governed by a staggering array of rules and regulations. When people’s lives are on the line, quality and safety aren’t optional.
Bureaucratic hurdles, however, often provide no such value. They build up in organizations overtime, like plaque in arteries, restricting flow, and slowing things down. If left unchecked, bureaucracies can effectively kill any organization.
This is where the Scrum@Scale concept of a minimum viable bureaucracy comes into play. A concept Dr. Raw and his team of senior leaders put into practice.
Take the need to upscale the number of ICU beds from 40 to 200 we noted above. That requires a lot of equipment, supplies, and space. The acquisition of which bureaucracy can grind to a halt. Dr. Raw proudly states, “we cut through a lot of that bureaucracy,” by creating direct channels of communication, a shared vision, and understanding of just what was required to achieve their goals.
A decision was quickly made to refit a former ICU ward that was now being used as a general ward. Additional space was needed, but this more than doubled their current capacity.
Next, they needed critical equipment. Dr. Raw gives the example of a machine that measures different blood gases, “we needed a second one when we opened the second ICU.” These machines are expensive, think tens-of-thousands of British Pounds. An acquisition like that, Dr. Raw says, “usually requires submitting a formal business plan,” which can take months to be approved.
Dr. Raw and his team, and their patients, didn’t have that kind of time. A point fully embraced by the hospital system’s executive team.
The hurdles and extra steps of bureaucracy were eliminated when the need was known and the value clear. Accountability and a streamlined process took hold. The approval for that blood gas machine was quickly given at one of their 10:00 am senior team meetings.
There’s a phrase Dr. David Raw uses to describe how it felt when the organization quickly aligned around this new way of working. It’s a phrase used by military doctors he works with, “We found our battle rhythm.”
Both Dr. Robert Macadam and Dr. David Raw welcome the opportunity to work with anyone and/or talk about their experiences. Please reach out to them via their LinkedIn profiles hyperlinked above.