One of the frequently repeating questions within Agile Business Transformation coaching centres around stakeholders questioning how agile can be applied to business processes as it is supposedly a software development methodology. Excluding the obvious errors in this assumption starting from the point there is no "Agile Methodology".  I thought it would be good to show how as a customer I went through a non-software development process this summer where the organisation has applied Lean Thinking and some Kanban practices to deliver a more customer-focused service.

So on to the main content and points of the blog. Unfortunately, in July this year 2018, I was given the diagnosis of Lung Cancer with a tumour in my right lung, uppermost lobe. My initial thoughts after this were influenced by the empirical evidence of personal experience in the past. I was not expecting a quick response from the existing health system. However, my expectations could not have been further from reality at least in the Health Trust area I currently live in South Tees. Within two weeks I was being brought into specialist clinics, and the options explained based on a very much Test Driven Triage system.

The test route is shown below in figure 1, but it starts from the identification of a tumour, is it a single instance within one lobe of the lung, is it Non small cell cancer or Small cell lung cancer (type), is it far enough away from the windpipe or other significant medical risk and has it spread to the lymph nodes. If after the first two have been identified as positive the others test as negative, then in South Tees the person will be a candidate for surgery and find themselves in a whirlwind of events to prove this and expedite the process to get the person to treatment as efficiently and effectively as possible.

Figure 1;



These test events on average I understand from discussions with my consultants are one per week although I did have to stall a couple until a second week myself to allow for conflicts I had with work commitments. They were accommodating in a couple of instances this happened and even taking account of that the lead time up to the surgery event or ‘Doing' in basic Kanban board terms was only six weeks.
Depending on how much the person involved is discussing with their consultants and treatment team. The person will soon figure out that a whole multi-disciplinary team has been considering the best routes to a favourable prognosis as an outcome even before the person was first given the diagnosis. This is to enable the Test Driven Triage process but also if at any point the person drops out of this expedite lane they are ready to support the person with alternative treatments.

If after completing the triage the person remains a candidate for surgery, they will undergo two procedures the first being a bronchoscopy/mediastinoscopy as a final check on the Lymph nodes and if this is clear the next will be the selected treatment surgery to remove the cancer. On turning up at the ward where the operation will take place the signs of Lean Principles and Kanban are evident. The person is met by their direct care team who will settle the person in and carry out the final checks for any allergies to the equipment and supplies that will be used in the surgery process.

Once this is complete, they are finished with the Planning phase of the workflow and as a work item are now ready to progress into the Doing of the treatment process. Depending on where the person is on the schedule the next phase is to be taken to the surgical theatre and once this is complete to the High Dependency part of the Ward for initial recovery. Then once in a stable condition returned to the normal rooms in the ward and over to the recovery care team who will look after the person until being discharged. Due to the nature of healthcare being 24 hrs it is not possible for a single set of people to form the care team for that whole period. Therefore, one of the standard practices in Kanban the Daily Stand Up is held at shift change over time. At this time the people assigned to the person for that shift will talk to each other directly within the overall group using the automatically and manually collected data to address any concerns or signify that the person is ready for discharge.

Just as in the Test Driven Triage there are test criteria that indicate successful outcomes after the surgery and some of these are automated while others require the care team to collect and interpret. These include such things as basic vitals blood pressure and oxygen rates both of which if the person is connected to the monitoring machines are automatically monitored by the central care team. Others such as air in the lung cavity, chest x-ray, physical movement and daily activities to take care of yourself are observed by the care team and questioned if they are happening when they take the support readings to the automated monitoring system.

Just as in Test Driven Development where a failing test is written that the developer must satisfy with a coded solution until the test passes. Initially, the tests are considered similar to failing as in the person hasn’t passed yet to get home. As the results improve and stabilise these Red Tests turn Green. When the care team consider the critical set of tests to be passed the persons' current treatment, e.g. the surgery is considered ‘Done’ as in Kanban terms for that particular work item.

It was interesting how they used the ward, rooms and bed almost as a physical Kanban Board with the person being moved around during each of the phases of treatment delivery. In addition, a blue folder is maintained with each person attached to the bed. This forms the single source of truth for every decision, treatment activity or outcome during the treatment. This blue folder stays with the person and their bed everywhere they go within the ward, and all results are added.

I started this blog from the position that the topic of adapting agile "software development" principles, methodologies and frameworks to non IT business departments is one of the common questions and myths. In the assumption that these are specific to software development and can't be adopted within business domains. This is even more prevalent when the organisations are in regulated sectors of the economy. If there are any readers of this blog article, who are currently facing the issues of adopting change within their organisation and considering how this can be achieved. Hopefully, this will give at least one example of how a transformation to a more agile in meeting customer needs way of working can be achieved.

It should be noted though that Business Transformation whether considering agile or otherwise is not identifying the correct new methodology which the organisation picks parts that allow them to continue working in the existing ways they have always worked. It requires identification of what value means to the customer and the organisation. So that organisationally the principles & practices that will deliver this value can be adopted to ensure the organisation continues to maximise its opportunities to the benefit of its customers and the organisation itself.

The underlying topic of the content and service provided can be somewhat emotional and may have affected people reading this in a negative manner. Therefore, I would ask everyone to focus on the application of Lean & Kanban as part of a transformation to being more agile in how they serve their customers and not add comments based directly on the medical condition itself. For those who know me and would like to send a personal comment, there is a multitude of ways to get in touch such as telephone, email or social media otherwise I will consider that all readers would send best wishes. I would also highlight that I can only comment on my route to and through treatment as that is what I have experience of. Although I expect that the decision making and process framework as being described is likely to have a similar structure.

The ultimate positive for all is that as the service provider moves more towards this way of customer centred delivery of treatment and a lot more treatments are coming online to allow them to do this. It will enable them to personalise outcomes to the need of the user in the same way the software development community has done with UCD and UX focused development.
If anyone requires further information on any of the specific topics related to cancer and its treatment, please consult with your medical practitioner and relevant information on Cancer Research UK.