Monthly Archives: February 2010

The Keystone Initiative: A Checklist Success

From Atul Gawande’s The Checklist Manifesto: How to Get Things Right, p. 44:

In December 2006, the Keystone Initiative [which used checklists in the ICU and integrated executives to help remove roadblocks] published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs — including the ones at [Detroit's troubled] Sinai-Grace Hospital — cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now — all because of a stupid little checklist.

This is the kind of thing that has to happen in every department of every hospital if we’re going to have affordable, first-class healthcare everywhere in the US. Unlike some other changes this one is relatively easy to implement and costs very little, with almost immediate payback.

Posted in Book Notes, Health Care, Life Lessons | Leave a comment

WTF Is It Going to Take?

Update from the day after: Just so that everyone knows, I’m not singling out any specific people or any particular party. I’m only angry at Congress and the pundits who are more concerned with scoring political points than with improving an obviously broken, expensive system. It’s true that I was angry when I wrote this, but it was an anger born of systemic frustration and not any specific interaction I’ve had. My anger was not directed in a partisan fashion; it’s a truly bipartisan emotion, with enough for each party. But now that I’ve railed, I can get back to the nonpartisan task of looking at all sides of this topic. As always, I welcome practical political dialogue — even of a partisan nature — with anyone and everyone interested in an honest discussion about what’s possible and what the trade-offs of these choices might be. Stay well!

I’m going to take a short break from my usually nonpartisan, constructive mode of looking at healthcare costs and reform. Please forgive me.

The fact that I might be inclined towards partisanship here is not something I relish. Sure, I have my political opinions. (Oh, do I have opinions!) But I’ve changed affiliations a couple times, so I believe that I have a little standing when it comes to understanding the opposing viewpoint. I don’t think either side is the enemy or stupid or destroying America or whatever mean thing one side says about the other. (Yes, it’s sad that’s what gets passed off as political debate at the present time.) So I do believe there’s more than just simple partisanship going on in Congress and around the water-cooler; I can understand why each side is deeply suspicious of the principles that underlie the other’s position.

But I am so very, very angry about what is *not* happening to get the legislation passed. And don’t even get me started about the weak content of the proposals and the counterproposals.

And when I say that I’m “angry,” I don’t mean rhetorical anger. I don’t have the luxury of rhetorical anger. Well, that’s not exactly true; unlike the under-insured, I do have very good coverage, and I live in a place with multiple care-providers for the same condition. But I do have a disease, and I use a lot of healthcare relative to the majority of the population. I don’t want to spend ever more money out of my own pocket each year for something that isn’t going away anytime soon. Worse, I strongly believe that a good portion of each dollar spent on my healthcare does not actually go very far toward providing a better chronic illness experience. And I suspect — but could probably never prove — that if we were able to spend less on disease management, we could probably invest enough of what we might save into actually finding the cure for diabetes and other expensive long-term illnesses.

I also have a nagging fear that I’m only one unfortunate life-event away from being in a truly terrible place with healthcare. If we’ve learned anything over the last couple years — and I’m not sure we have — it’s that even the “good jobs” aren’t always secure and that our wellness depends on being well-employed, which is somewhat out of our control. That’s unconscionable. In fact, it actually sounds un-American to me; and I think that if you disagree with that statement, then you and I have such vastly different notions of the American dream and our possibilities that I wonder whether we actually live in the same country, whether we were taught the same things about who we are as a people, whether we actually are or can be the great nation that we claim to be.

Why am I so angry? After all, I had planned to keep posting rational, dispassionate, argument-by-argument analyses of the different aspects of healthcare and insurance reform, building up to a convincing argument about why we should make a particular set of changes. So what’s happened to make today the day that I lose my composure and get ahead of myself?

It seems that after today’s White House-organized bipartisan healthcare summit, returning to an honest discussion about the need for changes and putting aside ideological differences seems unlikely to happen. So I’m going to be a little petty and then try to redeem myself with some realistic, practical suggestions that ought to be able to get bipartisan support. But right now, I’m angry.

In my black heart, what I really want is (a) for half of Congress to be without health insurance until a law actually fixes what’s broken with American healthcare delivery and spending and (b) for the other half to pay the same percentage of their income for healthcare as the 12% of Americans who pay completely out of pocket. Deep down in that dark place I don’t talk about at parties, I want to take this group of 535 people who are mostly beyond middle age and tell them this: “You haven’t been working, so you’re fired. You don’t have health insurance anymore except what you can get through COBRA (which was passed via reconciliation, I might add). And many of you will have pre-existing conditions so good luck getting reinsured under a generous plan. And since you don’t like governmental influence in the health system, we’re going to deny you Medicare or Medicaid — and SCHIP, too. (Because as rotten as you have been to us for the last few years, you deserve to worry about your whole family, too.) And you have to go home to your district for healthcare; I hope you live in a big city with lots of services, because you’re going to need them eventually. Some of you won’t be very lucky. If these new circumstances bankrupt any of you, I don’t care. Now you can suffer with the rest of us.”

I know, I know . . . it’s petty. But the social justice and humanitarian arguments have been ineffective in moving us toward consensus. Nor have purely economic arguments.* I don’t feel like I’m being hyperbolic when I say I believe healthcare reform is a matter of national survival. If the well-being of the nation isn’t enough to move the Congress forward, then I suspect greedy self-interest is our last hope to get meaningful reform passed. And right now Congress isn’t feeling any pain.

What do I think is “meaningful reform?” Without tipping my hand too much about what it could look like or how it might get implemented — I would like to continue investigating the various aspects of healthcare spending without favoring or dismissing any particular idea — here’s a broad outline of what I would very much like to see:

  1. Insure every American by mandate. You can refuse treatments if you want. That’s your business. But you can’t refuse to pay for insurance and/or healthcare. This is the very basis of insurance: Share the economic risk as broadly as possible so that over our lifetimes we pay the lowest possible amount.
  2. Ensure that no American can be denied insurance coverage, be dropped from any plan, or be forced to pay more than they can afford. Again, the goal is two-fold: everybody pays a reasonable amount at the same time that everyone has access to healthcare. (BTW, you can’t have this without an individual mandate. Universal coverage requires a universal mandate.)
  3. Reduce the administrative costs of private sector health insurance — if we keep that system — to the same level as government run programs (currently 2%).
  4. Discourage the use of the E.R. for routine care. For example, we might encourage producing more primary care physicians. We might also need to build more community-based, 24-hour primary care clinics for non-emergent care.
  5. Aggressively target the elimination of preventable chronic illnesses. Chronic illnesses — preventable or not — constitute up to 85% of all medical spending.
  6. Incentivize the use of evidence-based medicine. This means doctors and hospitals should get bonuses when patients do well and costs are low.
  7. Focus on waste reduction. In medicine this means choosing lower cost options (such as generic drugs and older scanners) whenever the outcomes are the same; lowering administrative costs; preventing medical mistakes; reducing the number of unnecessary, duplicated, and purely defensive tests; using electronic medical records that are shared by all healthcare providers; etc.
  8. Establish a national health strategy. We lack systemic coordination and goals. Ideas for goals include making wellness more prominent in policy, reducing preventable illnesses by encouraging positive lifestyle choices, improving rural medical access, implementing electronic health records, creating high-quality protocols, etc.
  9. Do some one-time changes that are politically palatable but won’t really do very much to lower costs: prohibit companies from advertising prescription drugs on television, over the radio, and in non-medical publications; reform medical malpractice; etc.
  10. Create a panel of medical professionals who can set reimbursement rates and maximum costs for all providers and insurers.

I am purposefully steering clear of issues where I think there are multiple good solutions. I don’t know enough about the potential costs, revenues, and savings of the choices. Maybe a single-payer system will make implementation of these goals easiest. Perhaps interstate competition between private insurers will lead to lower costs. If so, how would different states handle different requirements for covered services? Should we eliminate antitrust exemptions for insurance companies? Encourage co-ops? Create public plans? What role should the individual states play? I suspect there’s a place for federalism, with states as laboratories for innovation, but how much? Should we tax Lexus Cadillac healthcare plans? Reasonable people can come up with different conclusions on all these proposals.**

There’s one big, lingering, completely untouched question: “How much healthcare do we really need?” I won’t propose an answer. Everyone wants their healthcare completely covered, whether that’s continuous glucose monitoring supplies, fertility treatment, or experimental therapies for a rare disease. It’s something I grapple with myself. Unfortunately, it’s also the issue that led to the first (tragically) effective attempts to derail reform. (Remember “death panels?”) From a selfish perspective, I would also like to see a system where the chronically ill aren’t forced into higher cost plans.

And for most Americans that’s what it all comes down to: “What’s in it for me?” For Congress it’s a political game. For all the rest of us, it’s our health.


* — Healthcare costs are higher in the US than in any other developed nation. In fact, healthcare spending as a percentage of GDP is 50% higher in the US than in other countries, limiting what companies can pay employees and what individuals can spend and invest. Healthcare costs employers more than $2 per hour per employee, harming US competitiveness. And it’s only getting worse; by the end of the decade, spending will account for 20% of GDP. One out of every five dollars spent in the US will be go toward returning us to health or keeping us well. And on top of all that, Medicare will be insolvent by the end of the decade at current levels of spending, requiring higher taxes or reduced services if costs don’t come down.

** — Simply saying something is “socialism” is not a reasonable counter-argument. Show me why it’s bad. Prove to me that socialized health systems in other democracies have worse outcomes than the United States — because they don’t, and they’re less expensive. If you’re just “red baiting,” then perhaps you should stop, take a moment to reflect, and grow up. I’m back to being civil now; so let’s carry on our conversation without poisoning the well any further, shall we?

Posted in Diabetes, Health Care, This is who we are | 3 Comments

Random Bits of Awesome – February 2010

Dear readers, it’s time for a roundup of topics that just aren’t big enough for their own posts. I’m just going to jumble them all together. Enjoy!

It’s Olympics time. Woo! I don’t understand people who profess not to love the games. You may not like every event — bobsled, ice dancing, whatever — but how can anyone not love the whole Olympic ideal? Me, I particularly enjoy the nordic events, especially biathlon.

DiabetesMine interviewed skier Kris Freeman, the first type-1 Olympian in an endurance sport before the 30km cross-country race and afterward — I think he’s my new role model. They’re both great reads for any athlete with diabetes.

Freeman was “pissed” about going hypo during the 30km race, but he was “really, really pissed” about a bad ski choice during the 15km. I’m sure he will rock the 50km on Sunday!

Thinking of Canada, Lisa and I went to Montréal early in January. It was sooo cold (-14ºC for a high). How do people live that way? We went to see a J. W. Waterhouse exhibit at the Musée des Beaux Arts. While there, we ate some great food — check out Paris Crêpes on the corner of Ste. Catherine and Crescent — and I enjoyed the city’s polyglot lifestyle.

(And as for art: Last week the MFA installed its first painting in the new Americas wing. I can hardly wait!)

While we were in Montréal, I procured a bit of Francophone music. 90% of Canada’s population may live within 100 miles of the border that sees the most commerce between any two nations; but it’s almost as if there’s a Mounty-patrolled iron curtain separating the US from bootleggers French music. You can find a little bit on iTunes, but it’s hit or miss. Here are some names to look for: A.D.N., Amadou & Mariam, Marie-Luce Béland, Daniel Bélanger, Carla Bruni, Cali, Camille, Caracol, Les Charbonniers de l’Enfer, Cœur de Pirate, Les Cowboys Fringant, Étienne Drapeau, Dumas, Mylène Farmer, Grimskunk, Indochine, Kaïn, Karkwa, MC Solaar, Prototypes, Mara Tremblay, etc., etc., etc. The CBC nominated the top 50 Canadian francophone bands from this decade if you need more choices.

We also saw “Up in the Air” a month or two ago. Definitely recommended. It stars George Clooney, opens with a fabulous sequence of arial footage, uses a version of “This Land Was Made for You and Me” by Sharon Jones and the Dap Kings, and has a really strong story line. From time to time, I feel a bit like intern George‘s character — at least I share his attitude toward flying, but certainly not his brand loyalty (though I do have my preferences). But I’m not very savvy when it comes to getting the most of my air travel dollar, which is why I’ve been reading the Cranky Flier‘s web log.

Are you going on a trip anytime soon? Need reviews of places to eat, stay, visit? The Times gives a rundown of where to go online and in-print to figure where to go in real life. They mention TripAdvisor.com, IgoUgo.com, Oyster.com, and printed guidebooks. I’m starting to use TripAdvisor for hotel reviews, but books and magazines are still my destination for where to go and how to get there. Give me glossy pictures, a travelogue, and a map or two and I’ll be ready to pack my bags.

But my travel dance card is kinda full for a little while. I actually can’t believe how much I know about where I’m going in the coming years. Australia in just over three months. Bicycling in Provence, France sometime next year. England (and maybe Paris) in 2012. It’s not what I usually do . . . but I’ll take it.

More substance to come soon, I promise.

Posted in Australia, Crusty Old Paint, Cycling, Diabetes, General, Travel, Worthy Feeds | Leave a comment

Idea of the Day

If you don’t already subscribe to the New York TimesIdea of the Day weblog, you should.

(If I weren’t at work with a lot to do, I’d write about how it aggregates some of the best articles in print from the web concerning culture and the life of the mind. I’d say something about how it goes a little way toward fostering the kind of society-wide philosophical debates that are a common fixture in a certain Gallic country that I love. I’d delve deep into the contradictions between those last two sentences, digging into the inherent conflict between a time-shifted, remixed, excerpted, low-bandwidth form of communication (web sites) and the more active but ultimately futile discourse (about, say, the “hyperreal” in Jean Baudrillard’s Simulacra and Simulation) that tends to occur in the café or coffeehouse. But I am at work, and no one really wants to read about that anyway.)

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Checklists

We use checklists a lot at work. They help us reduce waste and ensure a high quality product. If we’ve run into a problem before, we’re likely to run into it again, so we might as well go down the checklist of “Did you think about this?” and “Did you do that?” items before submitting code into the repository.

But our checklists have gotten a little long and messy, which raises the risk that people won’t use them at all. Part of my job is to improve our team best practices and checklists, so I’m working out how to make all of those checklist-bound countermeasures fresher and more accessible.

So I’m very hopeful that Atul Gawande’s The Checklist Manifesto: How to Get Things Right, which arrived on my desk today, will give me some in-the-trenches perspective. I’ll keep y’all posted on what I learn.

Posted in Book Notes, Computing, Life Lessons, Software Engineering | Leave a comment

Good Times at the MFA Boston

This evening I went to the MFA to see the current exhibits. I was delighted by all of the daily life figurines that were part of the Tomb 10A exhibit. The Harry Callahan exhibit was small but enjoyable, and it was my first time seeing Dürer’s Melencolia in real life. (See picture #13 here.)

But the unexpected treat of the evening was “Bharat Ratna,” a collection of 15 paintings (plus one fabulous sari) by contemporary Indian artists. You don’t see a lot of modern Indian art here in New England — except at the Peabody Essex Museum — and this exhibit goes a long way to making up for that paucity.

I go to the MFA several times a year. It’s a wonderful museum — a world-class museum, befitting the wealth acquired by yankee industrialists, bankers, sea-faring merchants, and scions of American society. And it’s still growing. The trustees finished a major capital campaign before the recession hit, and I’ve been watching the progression of the new wing every few months when I visit. All of the construction fencing is gone, though it won’t open until “late fall.”

Because of the expansion, the museum has been creative in placing items from the collection. It’s a bit like a jumble sale, actually; but it makes each trip a unique experience. I suspect I might be seeing things that I wouldn’t normally go out of my way to view.

Of course, I’ve been reading a lot about European painters recently — currently Peter Paul Rubens, which is kinda funny since I don’t usually get into Old Masters, but he looms large in the world of the Romantics that I felt I owed it to myself to get acquainted with his work. Usually I just walk straight through the cavernous hall full of Old Masters — you’d expect to see Beowulf or Grendel in there, it’s so moody — stopping only at Francesco del Cairo’s ecstatic Herodias with the Head of Saint John the Baptist. But today I took my time and — behold! — there were multiple works by Velásquez and El Greco and even (OMG!) Rubens, too. Not the Prado or the Louvre, but still worth the longer look.

What really surprised me were the 19th century French works. I’m not a big fan of Rococo or Baroque painting, whatever the nationality of the painter. It’s just soooo gaudy and overwrought and . . . and . . . mindlessly happy. In the past, this has led me to treat the pre-Impressionist French painting salons much like the Beowulf/Grendel salon. But today I slowed down and looked at the paintings: Gericault, Corot, Nicolas Poussin, Claude Lorrain, and (OMG!) Delacroix. Not the National Gallery or the Met, but so much more detailed than the pictures in the books I’ve been reading.

And I’m actually really surprised at how skewed the MFA collection (as it has appeared on recent visits) is toward Romantic painting versus Neoclassical. Were 19th century New England collectors just that prescient? More cost-conscious? Did the Hudson River School (the “American Romantics” that were so popular in the early decades of the 1800s in the US) inspire a kindred desire for European Romantics? Was Neoclassical painting too old-fashion for a fledgling nation that had just thrown off the weight of European history? Too associated with musty academism? Too close to scary Jacobin terror? I just don’t know. Isn’t cultural history fascinating?

What will I see next time?

Posted in Crusty Old Paint, General | Leave a comment

How Much Does Health Care Cost?

So far, I’ve looked at how much my prescriptions cost (almost $6,000 per year) and how much the rest of my health care costs (about $7,100 or $4,250 depending on who you ask). Adding those numbers up, you get $10,250 – $13,100. My share is a bit higher than the American average of roughly $8,000.

That’s right, American companies and individuals spent an estimated 2.5 trillion dollars last year on health care, or about 16% of GDP. [1] That’s up from $2.2 trillion from two years earlier. [2]

Where are all of those dollars spent? The Kaiser Family Foundation published a briefing paper that breaks down the costs:

  • 31% – Hospital care
  • 21% – Physician/clinical services
  • 10% – Other professional services
  • 10% – Retail: prescription drugs
  • 7% – Program administration
  • 6% – Nursing home care
  • 6% – Investment
  • 3% – Home health care
  • 3% – Retail: Other products
  • 3% – Government public health activities

The New York Times presented the numbers slightly differently, but with similar findings for the year 2007:

  • 31% – Hospitals
  • 24% – Doctors (18%) and clinics (6%)
  • 10% – Prescription drugs
  • 9% – Nursing homes and health care
  • 7% – Dental service, other personal care
  • 7% – Administration
  • 6% – Research and construction
  • 3% – Government public health activities
  • 3% – Medical products (other than drugs)

Somewhere in all of those numbers is the amount attributable to medical imaging and diagnostics: about 6% of all spending in 2004 [3 (PDF)]. I’ve been interested in this figure for a while, since part of my work involves helping the engineers who build those high-cost devices and assays.

Overall, the amount spent by publicly administered plans is roughly the same as through private insurance (46% and 42%, respectively) with the rest coming out of pocket (12%).* The cost of administration is significantly lower in public plans than private insurance: less than 2% for Medicare vs. 7% overall.

Furthermore, it appears that there’s a lot of wasted spending in that $2.5 trillion: perhaps as much as 30%.

Based on more than 20 years of utilization research, Dr. John E. Wennberg, director of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, has established that nearly 30% of U.S. healthcare spending—roughly $630 billion annually—is spent on ineffective, redundant, or inappropriate diagnosis and treatment.

And 75% to 85% of health care spending is dedicated to treating chronic diseases. [4 (PDF), 5] The average per capita spending for the half of Americans without a chronic disease was a mere $994. While these conditions are certainly not all avoidable, many of them are.

Well, that’s enough data for tonight.


* — Basically, 12% of health care spending includes some of the most expensive per-service billings.

Posted in Diabetes, Health Care, Life Lessons, This is who we are | 1 Comment

Now Running WordPress 2.9

It took me forever to upgrade from WordPress 2.2. (Thanks, Internets, for not hacking my site.) After almost obliterating my web log in the upgrade process — thank g-d for backups and reversible changes — I’m now running 2.9.1, and it looks really great.

Now on to bigger and better things.

Posted in General, Life Lessons, MetaBlogging | Leave a comment

Massachusetts Healthcare Reform Costs

My auntie’s husband — I guess that would make him my uncle — baited me on Facebook into debating healthcare reform. I’ve been a bit coy discussing here what I would like to see in a healthcare reform package, preferring to lay out enough evidence to make my case plausible. But having been called out, I wrote a bit; and it makes sense to post it here.

Since the talk continues about nationalized health care, what about Gov. Deval Patrick in Massachusetts, where just two years into operation, the state’s mandatory health insurance plan is already costing $400 million more than budgeted? State run health care over budget in two years and many want National coverage… hmmmmm

The Massachusetts healthcare reform law was enacted in 2006, and almost immediately the number of uninsured people in the Commonwealth dropped to under 3%.* (The national average is over 15%.) It’s true that this includes an individual mandate with tax peanlties for adults who don’t have insurance through their employers and who also choose not to buy one of the options subsidized by state and federal money. It also requires companies with more than 50 employees to provide coverage or face a penalty. (But I don’t think it says how much of the cost the employer must pay and how much can be passed onto the employee.) The penalties for individuals and companies are modest — up to $912/year for individuals and $295/employee for businesses — and they are intended to get everyone into one insurance pool or another in an effort to lower premiums for everyone.

My uncle is correct about a budget shortfall. Most people can buy into a variety of private health insurance plans, as in most other states. They aren’t part of that shortfall. The Commonwealth Care plan provides coverage for people who make too much money to qualify for Medicaid or SCHIP but not enough to afford most private health insurance plans. I don’t know how much Commonwealth Care has experienced shortfalls, although it certainly has seen some. It doesn’t help that the statehouse sees Commonwealth Care as a place to make up shortfalls in other parts of the state budget, to the tune of $130M last year.

I don’t know if this is the $400M referenced earlier; that sounds a lot like the Medicaid/SCHIP defecit of $378M out of a budget of $8.7B for 1.2M people. That’s roughly 5% over budget, or $300/person in those low-income programs. (Last year the state cut $265M for this program.) Commonwealth Care only has a budget of $880M for about 160K people. But the state administers and subsidizes this low-cost plan, too, so it’s possible it is the program after all.

How much are Commonwealth Care premiums? For someone my age, 35, two-person plans start at $580 per month and run as high as $1,022 for something that looks a lot like what we have now through my employer. Here’s a comparison:

Seven different Commonwealth Care insurance plans


If we’re going to compare a hypothetical federal program with individual mandates to a Massachusetts plan, we should probably only really consider Commonwealth Care. It certainly is true that mandates haven’t really helped lower costs yet; that’s part of the yet-to-be-implemented second part of the reform program. And you may remember that the national economy tanked last year, which pushed a lot of people out of employer-funded programs into Commonwealth Care.

So what do I take from this?

  1. Even if we don’t have mandates for coverage, the government is already paying a lot for healthcare. But the mandate itself isn’t driving up the costs.
  2. Any program that involves individual/employer mandates needs to include cost control. Getting more people into the pool is necessary, but it isn’t sufficient to lower costs. Having people flee the pool does raise costs even more, though.
  3. Be wary of arguments that say insurance competition is all it takes to lower costs.
  4. We should focus a significant amount of our political capital on cost reduction mechanisms, but that’s pretty difficult since that’s where the hard choices have to be made: price caps for services and/or drugs; favoring the quality of outcomes over the number of services provided; focusing extra money on prevention and wellness instead of predominantly treatment; encouraging the entry of more physicians assistants and primary care physicians into the system; getting people out of high-cost ERs for primary care; maybe even penalizing people for poor health choices; etc.

But all of those topics are for another time. I need to find out how much they will cost, how much they will save, and how much they will improve our nation’s health.


* — I’m not going to source everything independently. I just don’t have the inclination tonight, since I’m watching the opening ceremonies of the Olympics. But here are the web sites I used to get my (hopefully correct) facts and figures:

Posted in Health Care, This is who we are | Leave a comment

Implementing Lean Software Development – Part 1

At midday yesterday my carpool buddy and I looked at the weather map, saw a scary blob of impending frozen doom, and decided to heed the Governor’s advice to go home. But the snow that was forecast — the blizzard that was supposed to mess up the evening commute — never really materialized here in the Commonwealth. Oh well. Only 1-2″ to shovel.

While working away the afternoon at home, I started reading Mary and Tom Poppendieck‘s Implementing Lean Software Development. I guess “rereading” would be more accurate, this time with an eye toward actually implementing the ideas. Here are my notes from the first few chapters.


What is Lean Production?

  • Use just-in-time (JIT) flow of work products.
  • Stop the line to fix problems as soon as they are discovered.
  • Eliminate stockpiles of in-process inventory. Create small batches.
  • Make mistakes impossible from the beginning.

Product development is knowledge creation via exploration of designs, experimentation with prototypes, and integration meetings that evaluate designs and make decisions.

Schedules have synchronization points, but let expert workers function autonomously between them.

Explore multiple options and make competing prototypes. Defer the decision about which to actually build until the right time (usually later than you think).

Software should be easy to change. Employ all of those high-quality best practices and metrics during construction.

The Toyota Product Development System — upon which the Poppendiecks base their book — is very empirical. The final idea/design/product emerges during development. At the outset, define the goals to meet, not the technology or architecture you’re going to use to satisfy it.

1: Eliminate Waste — Minimize the time from request to fulfillment

  • Waste is everything that doesn’t actually add value to a customer feature. Focus on value.
  • Reduce the amount of partially done work (inventory). [Basically, don't work on what you haven't been asked for, and complete what you start. Get it written, tested, checked-in, and reviewed.]
  • Reduce the time between requirements, coding and testing. This helps reduce requirements churn. Use test-driven development (TDD). Shun “big bang” integration.
  • Avoid extra features and scope bloat.

2: Build Quality In

  • Control the conditions for creating quality components, preventing defects.
  • Write tests first. Use TDD.
  • Continuously integrate. Integrate code and tests together.
  • Write less code. Keep it clean and simple. Don’t duplicate. Refactor.

3: Create Knowledge

  • Go from a sketch to detailed design during construction.
  • Release a minimal set of functionality to customer for feedback.
  • Create daily builds and get feedback (knowledge) from integration tests.
  • Have an experienced team. Pour learning back into the team.
  • Build a modular architecture that supports adding/changing features as you learn more.
  • Generate new knowledge through disciplined experimentation. Codify that knowledge and make it available to the larger organization. Build a knowledge base. Encourage long-term thinking.
  • Continuously improve processes.

4: Defer Commitment

  • Try to make most design decisions reversible/undoable/nonbinding.
  • Schedule irreversible decisions for the last possible responsible moment.
  • Always move toward the concrete, and identify where change is likely to occur.
  • Experimentation reduces the risk of making the wrong decision.
  • Planning is an exercise, but plans are overrated. Avoid “plan-driven methods.”

5: Deliver Fast — Compete on time

  • Be faster than your customers’ ability to change their minds.
  • Requires low defect rates, high quality processes, good understanding of the customer.

6: Respect People

  • Favor ownership at the worker level, not top-down.
  • An entrepreneurial leader should own the product and foster engagement.
  • Develop and nurture technical expertise as a competitive advantage.
  • Give general plans with reasonable goals. Then let the group self-organize to meet them.
  • There is no “one best way.” There is continuous improvement, though.

7: Optimize the Whole

  • Optimize the whole value stream, that is, not just local processes.
  • Pay particular attention to where products,code and processes transition between departments, teams, organizations or physical locations.

The product development timeline:

  • Concept — What’s the unmet customer need or desire?
  • Feasibility — Test feasibility by experimentation. Build stuff. Ship betas. Design systems. Investigate the major features of the business process, key hardware modules, interfaces, boundary behaviors, software architecture and constraints. Can the product really be built? Will it work?
  • Pilot — Work with your customers. Show off the product; collect data; iterate. Let people choose from multiple options by playing and “voting with their attention.” Run multiple pilots to refine the design.

You have to go way beyond meeting basic expectations, even beyond adding new features or improving performance. You have to identify needs customers don’t know they have and then delight them by meeting those needs. This requires developing a deep understanding of the customers’ world.


That’s all for now. I’ll post more as I continue my way through the book — perhaps the next time it “snows.”

Posted in Book Notes, From the Yellow Notepad, Software Engineering | Leave a comment