In a 2017 presentation, Sidney Dekker describes a review of safety outcomes within a hospital. Investigations of root causes of failure included human errors, procedural violations, and miscalculations. However, investigations of successful outcomes identified exactly the same root causes of success: human errors, procedural violations,

Which brings us to Gantt charts. In Chapter 0, I gave an overview of the Gantt chart. Created by Henry Gantt, who worked with Frederick Taylor in the early 1900s, it was originally called a Man Record Chart. A line represented whether a worker had shoveled enough coal or moved enough crude iron for the day, as determined by the “foreman.” The

Instead, it is necessary to optimize for early and often learning in a real environment with real customers or consumers. This lowers the risk of delivery, generates value earlier, enables pivoting to maximize value, and locks in progress as you go. The best part is that, unlike pouring concrete, which sets, with knowledge-based products and

As per the Cynefin framework (Chapter 0), in the “Clear” and “Complicated” quadrants work is predictable and a fixed, standard approach to mitigating risks may be appropriate. However, “Complex” product development is unique. It has not been done before, either at all or in context, and there are unknown-unknowns. There is a need to focus on

In The Unicorn Project, Gene Kim defines five ideals of DevOps:24 1.Locality and Simplicity: alleviate dependencies between teams and components. 2.Focus, Flow, and Joy: the smooth flow of work that enables focus and joy. 3.Improvement of Daily Work: continuously improve and pay down technical debt. 4.Psychological Safety: a top predictor of team

The pattern is to craft a why for change that people will buy and that is unique to your organization. And then repeat that why. Communicate this why three more times than you think you need to and you’re a third of the way done. A tip here is that when training for any way of working, whether that training is run internally or externally, have the

Lean and agile, with a common root in post–World War II Japan, have a lot in common, such as a focus on building quality in, value, flow, respect for people, a pull-based system of work, and a kaizen process of continuous improvement and visualizing work. However, a key area where they differ is the focus on “standardized work” in lean. Mass

The human employees on the factory floor do work that is specialized and in harmony with the machines. Toyota calls this “autonomation” or jidoka in Japanese, which can be roughly translated as automation with a human touch.

In my experience, the application of Agile frameworks usually leads to a revolutionary approach. Most frameworks are largely prescriptive and are explicitly described as immutable. When all you have is a hammer, every context will be treated like a nail. And when you’ve paid a lot of money for a gold-plated hammer, when you’ve trained a lot of