R&D speed to market

Many of the diseases that our parents and grandparents suffered from as children are no longer a concern thanks to the advances in pharmaceuticals and treatments. Aggressive research and progress continue to find cures and prevent both chronic and terminal illnesses. But we want to save more lives, and save them faster.

Customer expectations regarding healthcare and the miracles of science are rising. Payers within the healthcare system are drilling down to find the best value in the medicines and treatments they’re buying.

Pharmaceutical companies are under constant pressure to devise new medicines to keep up with the stiff competition. Yet they must do this within a cost-cutting and economizing environment. To compete and succeed, they have to be the fastest, most nimble, and most cost-effective — as in every other industry I’ve looked at in this book.

Yet big pharma’s output has, on the whole, stayed flat. Most pharmaceutical organizations are tackling new situations and technological advances with the same project management frameworks used in the 1940s. They’re surrounded by new ways of doing business, yet have mostly stayed within traditional management mind-sets.

Scrum can offer some positive change in the following ways:

• Every experiment begins with a hypothesis. In scrum, this is the release goal.
• To test the hypothesis, a series of premises need to be true or false. Each premise is a sprint goal. The sprint backlog is broken into tasks and experiments needed to fully explore each premise. The definition of “done” for the sprint outlines the type of tasks and activities that must be conducted and accepted for a premise to be considered fully tested and explored.
• At the end of each sprint, the team presents its findings to stakeholders, who ask questions and validate the team’s sprint conclusions. Stakeholders should include representatives from regulatory teams. If something was missed, the scrum team knows it early instead of at the end of the entire set of sprints in the release. They can conduct the follow-up activities to address the feedback in the very next sprint if it’s a priority.
• After all premises have been validated, the hypothesis either stands or is invalidated. Either way, it’s a “releasable” conclusion.
• All the actions needed to test the hypothesis are the requirements on the product backlog and get prioritized accordingly.
• With new products or improvements on old ones, scrum allows you to iterate quickly. The mantra of “fail fast, fail cheap” means that you can be as nimble as you like with trying new ideas and processes.
• Self-organizing scrum teams allow developers to come up with the best research and solutions.
• Customer, business, and regulatory involvement (as stakeholders) throughout the process means constant feedback and direction. Because of this, accountability is shared and engagement rises.

Scrum frameworks have actually been used by several medical-device manufacturers with much success. Abbott Laboratories scored a hat trick when it achieved time-to-market savings of 20–30 percent, cost savings of 35–50 percent, and fewer software defects. Employee morale also increased.

Reducing mistakes, increasing quality

While we have the greatest technology and treatments ever known, we still have room to improve. Incredibly, mistakes during healthcare delivery in America are now the third-highest killer. The actual numbers are nothing short of astounding:

• The Journal of Patient Safety recently conducted a study that estimated that over 400,000 people die every single year from preventable mistakes that occurred while they were in the hospital.
• According to a 2010 report from the Department of Health and Human Services, 180,000 Medicare patients die every year from preventable hospital mistakes.
• In 2011, the Centers for Disease Control and Prevention indicated that 1 in 25 patients gets an infection from their hospital stay, 700,000 of these individuals get sick from their hospital-borne infection, and a tragic 75,000 die.

A report by the Journal of Health Care Finance estimates that these medical errors, if you include lost productivity in the workplace, may total up to $1 trillion annually. In many cases, these errors can result in a device or medicine getting banned forever on a very short notice, resulting in a complete loss to a company that has invested billions of dollars during the development cycle.

While the causes of these errors may vary, the quality assurance built into the scrum framework can ferret out problems and their solutions early. System inefficiencies, bottlenecks in work flow, communication breakdowns, lack of timely feedback — all these can be more easily identified and dealt with while using scrum. Looking at it more closely:

• As communication is increased, inefficiencies become visible. Scrum exposes these through daily scrums and sprint reviews; real solutions can be tried, tested, and adapted.
• While licensed physicians are the only people authorized to diagnose patients, self-organized teams (of the entire staff) facilitate the necessary treatment, rather than the command and control system of the highest-ranking physician.
• Feedback is rapid, and adjustments can be quickly implemented and retested.
• As quality goes up, unnecessary risks and wasted costs go down.
• As input from all members of staff and key groups is sought after and used, buy-in increases and morale improves. This is hugely valuable in healthcare, where many people are overworked and burnout can be high.

Scrum has been used within the healthcare environment with great success. It starts with administrative buy-in, followed by the implementation of scrum teams and their inherent roles. Then the process begins, following the roadmap to value just like any other scrum project. Follow the stages I’ve outlined along the way and watch the positive changes unfold.

Cost cutting

Those words alone are enough to perk the ears of any healthcare administrator. And in a sense, every single problem and solution I discuss will help save costs. Avoidable illnesses and deaths, increased efficiency in care delivery and administrative flow, ease in following existing and new regulations — pretty much you name it — can be improved and it will save costs.

Cost savings are a hallmark of scrum. Not only do you achieve an increase in speed to market, which accounts for a large part of the cost savings, but you also streamline processes, remove inefficiencies, and generally make better business decisions. For instance, as reported by the Center for American Progress in 2012, “administrative costs in the U.S. health care system consume an estimated $361 billion annually — 14 percent of all health care expenditures in our nation. At least half of this spending is estimated to be wasteful.”

Consider savings in the context of unnecessary care costs. A 2012 study conducted by the Institute of Medicine estimates that we waste $750 billion annually on unnecessary healthcare. The causes range from inefficient and unnecessary services, to overpricing, to excessive administration costs, to fraud.

Some of the ways scrum can help are

• Sprint retrospectives: Scrum makes it habit and culture to consistently and frequently ask such questions as
  • What about our claims process is unnecessary?
  • How can we minimize repeat patient visits?
  • What additional steps can we take to reduce patient risks even further?
  • Where are the bottlenecks?
  • What if form XYZ were electronic?
  • What’s stopping us from increasing our daily claims processing rate by 20 or 50 percent?
• Daily coordination of priorities: During daily scrums, such questions as these can be asked:
  • Is this necessary for this patient today?
  • What’s in the way of this patient going home well today?
  • How can we remove that obstacle?
• Transparency and simplicity: With scrum, you want to maximize the amount of work not done, especially if it’s also harmful. This is essential. For example, reducing the number of early elective deliveries (37–39 weeks as opposed to 40) would eliminate up to 500,000 neonatal intensive care unit (NICU) days.

All those regulations!

With the changes brought on by the Affordable Care Act (ACA) in 2010, along came a flurry of new regulations. Whether more or less in quantity, they’re certainly new, and a huge learning curve lies ahead for healthcare service providers in integrating these new rules.

Whether the ACA, FDA, IEC, HIPAA, or any other alphabet-soup acronym in the healthcare field, these regulations are in place to protect patients and healthcare providers, and each healthcare organization needs to find ways to comply. Implementing solutions to address new regulations can be challenging and even tedious, and with fewer resources to work with, it can be all the more daunting.

Here are some of the ways that scrum comes out on top in regard to understanding and abiding by new regulations in the healthcare industry:

• A product backlog can be created and prioritized by business value and risk mitigation. The scrum teams and organization as a whole then have the rationale to make business and resource decisions during the complex times of regulation changes.
• Previously, the technical and business sides of healthcare solutions might not have met eye to eye. After all, their mandates were probably different. But as the business side is covered by a product owner, and development teams are formed to design solutions, all of a sudden goals come in line. Scrum team roles are peer roles, working together to facilitate the right environment for aligning goals and purpose, which is ideal for implementing changes to deal with regulations.
• Self-organized teams help define the best solutions. When the new regulations are narrowed down and prioritized, it’s easier to pinpoint solutions and implement them quickly.
• The evolving regulatory requirements can then be built into the scrum team’s definition of done. This way, product owners and stakeholders can rest assured that they’ll be in line when audits and inspections take place.

Scrum doesn’t escape regulations. Regulations have the good of the patient in mind. Scrum is a tool for responding to changes by being tactically flexible while remaining strategically stable, and thereby making sure that the end goal — better healthcare — is achieved.

Electronic healthcare records

Converting patients’ medical data into electronic healthcare records (EHRs) is a monumental task. EHR is attractive for making healthcare more efficient and less expensive, for improving the safety and quality of care, and for convenience to patients. But the scope of data conversion is huge, entailing high cost and labor. It’s estimated that between 2010 and 2011, hospital adoption rates have risen from 11.5 to 18 percent. But that leaves a significant 82 percent left to go.

One of the problems with EHR conversion is that no set consensus exists of what the end result will actually look like. The benefits aren’t clear to everyone involved. Of course, this is where scrum’s foundation in empiricism excels. Empiricism asserts that knowledge comes from experience and making decisions based on what is known. We start with what we know, create a product backlog, prioritize it, and begin developing those at the top. With the feedback loop in place, you’ll quickly start seeing what works best.

Some of the issues with EHR conversions are as follows:

• The number-one issue within healthcare providers is finding the financial resources to undertake the EHR conversion.
• Significant amounts of data entry are involved.
• Integration issues arise, such as designing software so that EHR software with different standards can communicate.
• Privacy concerns. Many EHRs aren’t shared between organizations currently, but the goal is for all healthcare providers and organizations (such as labs, specialists, medical imaging facilities, pharmacies, emergency facilities, schools, and workplace clinics) to be able to securely share information involved with a patient’s care. Making this conversion seamless brings in privacy issues and ensuing legal liability ramifications.
• Independent practitioner physicians with varying degrees of loyalty to care delivery organizations have different mind-sets, which make EHR conversion efforts challenging.

Scrum addresses each of these issues in the following ways:

• Scrum reduces costs and budgetary commitments.

• AC + OC > V: Terminate the project as soon as the actual cost (AC) of the project added to the opportunity cost (OC) of not working on other projects is greater than the value (V) you’re expecting to get from the future functionality. See Chapter 5.

• With scrum’s incremental approach, only the highest-priority requirements are completed first, and therefore can be funded incrementally rather than all up front (for more on incremental funding, see Chapter 13). With this in place, items that don’t matter as much, or may not actually be needed at all, are left until last. This alone increases cost savings.
• Inspect and adapt. Scrum allows you to identify problems, like unexpected HIPAA privacy concerns or legacy data compatibility issues, early on before they cause reams of damage. The best solutions can then be found and tested again. Identifying these issues early on saves money in fixing them much later.
• Common definition of “done.” Scrum brings transparency by defining common standards, so independent practitioner physicians can share a common understanding of EHR implementation within an organization. A common language approach referring to the new EHR process can increase the adoption rate for this monumental mandate.

Medical device manufacturing and safety

In line with the pharmaceutical industry’s need to produce new and amazing medicines, medical device manufacturing firms have their own set of issues — some of which overlap. They, too, live within highly competitive and cost-conscious environments.

As with pharmaceuticals, many are beset with traditional project management mind-sets. Up-front designing, combined with late back-end testing, means that defects get detected late and the costs for fixing them rise. And that’s assuming that the defects are detected before the product hits the market. See the “Pair programming” sidebar in Chapter 4 for the exponentially increasing costs associated with defects.

With scrum, you can

• Build product testing into each iteration. Catch those defects early, stamp them out, and implement better designs.
• Colocate designers with engineers so that they’re immediately accessible and can have real-time everyday feedback.
• Many times the customer doesn’t know exactly what they want right at the beginning. Only after the initial high-priority requirements have been developed can they see a fuller picture. Scrum allows for this.
• Inspect and adapt constantly. Only build what’s most important, and test and garner feedback regularly and frequently.
• Get daily sign-off with the product owner on work done.
• Receive feedback from stakeholders at regular sprint reviews. This gets them involved throughout the development process.
• When syncing software and hardware development, the teams can coordinate early and often.
• The definition of done for both teams can include integration and testing throughout each sprint rather than at the very end.

GE Healthcare

GE’s imaging unit found the following ailments in its traditional approach to developing these types of medical devices before implementing scrum:

• Predictability: The company was running 12–24-month projects, usually with significant delays.
• Scope creep: Those representing the business usually pushed to add features beyond the original scope.
• Phased gate approach: Minimal customer interaction until the first round of testing was a major contributor to delays and soaring project costs.
• Silo teams: Artificial barriers existed between functional, technical, and business units in the organization.

Scrum healed these ailments in the following ways:

• Product owners were an integral part of the scrum teams. This alone significantly broke down silos and aligned priorities across the organization. The whole business began working in unison to release the right product to customers on time.
• Short sprints in which actual product increments were completed and demonstrated. The feedback received early on steered the project to earlier project completion than normal.
• Senior leadership excitement. Early on, by observing successes at one of their joint ventures using scrum, executive leadership caught the vision of what scrum could do, and their support accelerated adoption.
• Due to high regulation of the industry, GE built regulatory steps into the definition of done and acceptance criteria. Development teams adjusted to this level of effort when estimating and executing.

By incorporating scrum into the medical device manufacturing process, costs come down and time to market is reduced, but most importantly, defects are reduced, resulting in less reputational and regulatory risks. The chance of a product actually harming a person goes down because the product has been tested and integrated so many times already. In the end, this is what matters.

Curriculum scope increase

Remember the days of “reading, writing, and arithmetic”? The curriculum requirements for teachers have been expanding for decades. More information is required to be covered, and teachers can be overwhelmed just trying to keep up. These curriculum pressures come from three sources:

• School systems and governments
• Parents
• Students

No Child Left Behind (NCLB) in the United States is just one government program that’s been introduced over the years. With NCLB’s emphasis on standardized testing, teachers were given a new set of parameters to work toward. Over the years, other programs from all levels of government have left their mark as well. Although many of these programs bring high-quality elements to the school experience, each also leaves a new mark, which often means more work.

Many topics and experiences used to be taught in the home by parents. School was for the basics. Now, school systems cover subjects never before imagined in the classroom. A few that were introduced just in the last decade are listed here:

• Bully prevention
• Antiharassment policies
• Body mass index evaluation (obesity monitoring)
• Financial literacy
• Entrepreneurial skills development
• Health and wellness programs

Nothing in itself is wrong with these additional programs. In fact, they look great. However, teachers are being asked to include some of these topics, along with many other new ones, and of course, the old standards of reading, writing, and arithmetic. Yet, they’ve been given no more actual hours in the day for teaching, and often work with limited resources and funding.

Students themselves arrive with a host of experiences and knowledge that would have been science fiction just a few decades ago. They’re often computer literate by their early years, and have been exposed to adult themes and messages through TV, films, and music. While the teaching techniques I mentioned previously are inherently scrum, the actual spectrum of what’s being taught has increased. But the overarching goal for everyone remains the same: well-educated students.

Effective prioritization and inspect-and-adapt methods are essential to effectively administer this growing curriculum. Teachers do this as they carefully plan each day and empower students to be self-organizing and self-managing. Rather than following a strict, rigid plan outlined at the beginning of the year, they regularly conduct assessments and adjust their schedule, sometimes spending more time than planned on a subject to help a struggling class, and sometimes spending less time than planned when a class just “gets it” quicker than expected.

More and more, teachers are also recognizing the value of “refactoring.” In the old days, you took a test, you got a grade, and that was it. For better or worse, that was your grade, no questions asked. As educators have learned from experience, adaptations have been made to allow students to learn from mistakes and be rewarded for their learning. Continual feedback loops allow for learning, followed by an assessment (a pretest or quiz), with feedback and more learning followed by the final assessment. Rather than the grade being the only goal, students are starting to also understand and appreciate what they learn using these same events as used in scrum.

Moving low-performing students upward

Teachers are hugely instrumental in moving individual students through learning blocks and helping peel them off the lower rungs of performance. However, sometimes teachers work from a structured curriculum that requires them to move on with new topics and subjects even though not all their students may have full comprehension. While they might want to spend more valuable one-on-one time with each student, they simply can’t and still keep the overall curriculum moving forward.

Therefore, the individual attention needed to help low- or moderate-scoring students sometimes isn’t available due to lack of time. Teachers need to keep progressing in their curriculum. Large class sizes can add to this conundrum.

According to the National Center for Public Policy and Higher Education, every school day, 7,000 kids drop out of high school. That’s over a million each year. In the end, we’re producing fewer candidates for high-level careers.

As a result, low-performing students arrive in their next year’s class without a full understanding of the previous year’s material. Or, they’re held back and taught the same material over again without new learning techniques. Evaluations are done, but teaching doesn’t necessarily circle back to those weaker areas of understanding.

According to the Carnegie Foundation for the Advancement of Teaching, more than 60 percent of students entering a community college today in the United States need to complete developmental courses before they take normal college-credit courses. Of these, 70 percent fail these developmental courses. This blocks their way to higher-level math and technical courses and stumps their career possibilities.

Success in elevating individual students comes through collaboration among schools, teachers, parents, and students. What if the scrum framework were applied for each individual student, with team members consisting of such participants as the teacher, the student, the counselor, a school administrator, and a tutor? This team could set iterative goals leading to an end goal, with regular feedback loops, all the while inspecting and adapting progress and the process to tailor-fit the student’s needs.

Most schools are always trying to get more buy-in from parents and the community. In one school I’m aware of, when the teaching staff wanted to change the discipline plan, they did several iterations of revisions and feedback sessions until finally it was implemented. Following implementation of the new policy, iteratively addressing concerns and changing the behavior of teachers and other staff members were to follow.

Increasing student-to-teacher ratios

Classes are getting bigger, and therefore individual teacher-student attention is dropping. It’s a tall order to manage the entire class and the increasing curriculum, and provide student- and subject-specific teaching.

For example, in 2010, Georgia cut funding for its state schools by $1 billion, after which the State Board of Education was forced to lift limits on class sizes. The Board simply didn’t have the money to hire enough teachers and keep class sizes down.

Teachers spend time building relationships, modifying a lesson, executing lessons, and helping students one on one. Finding time for this is the most important challenge of education. As funding decreases, but yet teaching methods and systems stay the same, it’s inevitable that education in the classroom will suffer. Scrum can help leverage teachers’ time and increase adaptability.

I go into how scrum can address these roadblocks in the next sections.

How one teacher approaches scrum

So how does it actually work, this scrum-in-the-classroom concept?

The best part is that kids love it. They become active participants with the white boards and sticky notes and the responsibility of making sure that each bit is in its proper place.

But I want to delve into some real-world examples.

Following is how one teacher approaches scrum in the classroom:

1. Set up a project of one to five day’s duration.

   It’s effectively a sprint. The teacher has the original plan, but they get class buy-in through listing requirements. If the project is to understand the periodic table of the elements, for example, requirements could be sections of the table. Tasks might be the individual elements themselves.

2. Scrum teams of students are formed, and they decide who fills each of the scrum roles as a team.

   A high degree of autonomy is placed on these teams.

3. A project backlog is created, often utilizing a task board.

   The kids write down the requirements. The teacher facilitates as a scrum master and keeps everyone focused.

4. Using sticky notes on a white board, wall, or blackboard, children get involved with ordering and prioritizing them.

   Children love the sense of accomplishment that comes from seeing things move from to do to doing to done.

5. Each project session begins with a daily scrum. The students are actually using scrum language, like daily scrums, scrum master, and sprint reviews.
6. At the end of each sprint, conduct both the review and retrospective. Buy-in increases, and when appropriate, the students can contribute to the goals for new projects.

Children enjoy the hands-on process and progress. They can quickly see progress and are amazingly flexible in adapting. In short, as you saw in The Marshmallow Challenge in Chapter 1, kids naturally think in terms of the iterative process. Scrum is just a formalized way of dealing with natural brain wiring.

eduScrum

In a town called Alphen aan de Rijn in The Netherlands, scrum is being used in a high school and secondary educational college. It is called eduScrum and educators using it are experiencing amazing results.

Teachers and students are using scrum in all subjects, and they form scrum teams with all the scrum roles intact. Three teacher scrum masters are leading the charge, each facilitating the process in their respective class. They also conduct daily scrums on the projects, and sprint reviews and retrospectives. They collected data on the results of this process with 230 students, ranging in age from 12 to 17 years old.

The quantitative results were impressive. In The Netherlands, test scores fall in a range of 1 to 10. A score of 5.5 is fine, but students strive for 6.7 or better. The students participating on teams using scrum consistently outperformed those who didn’t by a range of 0.8 to 1.7. In terms of percentages, these are significant increases.

Furthermore qualitatively, half the students said they

• Understood the subject material better
• Had more fun (hugely important for learning)
• Could work harder and faster
• Felt they were learning in a “smarter” way

Teachers also noticed greater engagement from their students and an overall more positive experience. Interestingly, this is often what corporations and organizations report when they incorporate scrum — improved employee morale.

An interesting side effect of scrum in schools was that the students reported just plain having more fun with classes and learning. This made them more eager to go to school and participate. And those shy, quiet types? They flourished as their skills and contributions were noticed in the reviews and retrospectives.

The team atmosphere also came out shining. Well over half the students learned to cooperate better and developed trust in their team members. They opened up to giving and receiving feedback, and the teachers noticed a more relaxed atmosphere.

Blueprint

Blueprint High School in Chandler, Arizona, is a nonprofit organization that creates and implements special education options. It sees using scrum in its classes as a way to prepare its students for the twenty-first century workplace.

Leaders at Blueprint High School decided that having a high school diploma wasn’t enough to prepare the school’s students for the twenty-first century. They also needed skills in collaboration, creativity, accountability, critical thinking, and teamwork. Interestingly, these are all qualities that scrum naturally fosters.

One of the key components in teaching scrum was getting students to go from determining the “what” in their projects to the “how.”

With Blueprint, the scrum roles were more flexible based on the individual team context. Sometimes the teacher would be the product owner or scrum master, and other times, the students took on these roles. As the teams matured and garnered more experience (as young as fourth-graders), they automatically took over the role of product owner. The teachers simply identified the type of projects to be completed, and then the students took over by developing their own goals, implementation, and reviews.

Collaboration and teamwork skills took off.

While Blueprint didn’t conduct the type of quantitative study that eduScrum did, Blueprint experienced many positive anecdotal outcomes:

• Greater student engagement
• More fun
• Greater empathy for each other
• Independent thinking
• An overall more positive educational experience

One teacher even said that her kids would even come in if they were sick because they didn’t want to miss a single day of school! That really is wholehearted buy-in from students.

Cybersecurity and warfare

Cybersecurity and warfare are the new global battlefield. Frequent, fast, and thorough inspection and adaptation to keep up with, and even stay ahead of, attackers will be crucial to a nation’s survival.

The United States Department of Defense (DoD) has implemented a series of Information Assurance directives (8570.01 and 8570.01-M), ensuring certification baselines for security essentials. These encompass a broad spectrum of skills and focus areas. These certifications correspond to the individual’s level of responsibility and experience, and they all require continuing education to maintain the most current skill sets.

The primary challenge is to always be prepared for an enemy of unknown size and sophistication, who may have unlimited resources and the ever-growing threat of exploitation due to changes in technology. All active participants are constantly striving to be bigger, better, and faster than their adversaries.

DoD components will often assign a tiger team to address an incident that requires immediate attention and requires a collaborative and expedient solution. The teams are small and consist of a combination of specialists and cross-functional members. The primary goal of the tiger team is to run the problem to ground and document the results through after-action reports and repositories for lessons learned (retrospectives resulting in actionable improvement plans).

Like special forces, tiger teams have close parallels to scrum. Although they will usually have a defined leader, they are typically wholly collaborative and are accustomed to flexibility in response to a changing environment as they address their respective incidents.

Scrum and the FBI

Cyberattacks of all sorts, from credit card hacking to government and military security threats, are increasing around the world. Military and cyberwarfare experts agree that controlling this expanding threat is a major concern. Cyberthreat deterrence programs that can adapt to the ever-changing nature of these sophisticated challenges are needed — and needed fast. In many cases, it’s an issue of national security.

The FBI has been increasingly active in finding solutions for responding to these cyberattacks on a national and criminal level. Leadership knows that using old techniques for handling these uber-modern threats isn’t enough. New ways of applying technology, shaping their workforce, and collaborating with partners are required.

Not surprisingly, they’re approaching this conundrum with scrum in mind.

As published by the FBI’s Information Technology Strategic Plan for FY 2010–2015, the FBI is in fact creating

“. . . an agile enterprise with evolution toward consolidated and shared infrastructure, services and applications. As part of the agile environment, the FBI will sustain a rigid information security management program, implementing tools and processes to enhance utilization of the Enterprise Architecture (EA) through virtualization and abstraction. Strategically, the FBI will focus on fully understanding, adopting and integrating a shared services approach to IT and business challenges.”

After the 9/11 terrorist attacks, the FBI began to work on streamlining its flow of information and coordination with all relevant entities. After a couple of false starts, it developed the Sentinel program: a comprehensive software case management system. The goal is to replace a current system consisting of a mixture of digital and paper information flow with a purely digital one.

For ten years, the project was conducted using the FBI’s prescribed waterfall methods, including extensive up-front design and fixed requirements. In 2008, a new CIO, Chad Fulgham, started requiring incremental delivery from the contracted developers. Specifically, by 2010, scrum was used officially. Here are some of the symptoms of the waterfall process used up to that point:

• Only 4 of 18 workflows were live, but with defects.
• Less than 1 percent of the 14,000+ forms were created in the new system.
• Cost to date was $405 million, with an estimated $350 million more to go over six years.
• All delivered functionality was considered optional throughout the organization.

When scrum was implemented, excess staff was cut by more than 50 percent, user stories were created, and 21 two-week sprints were scheduled — an 85 percent decrease in projected schedule.

Healthcare, education, and the military and law enforcement all have one important thing in common — people’s lives: our health and well-being, our knowledge and preparation for the future, and our security. Scrum works in each of these areas, in real lives, for real people, and for real changes for the better.