In his 2014 Reith Lecture for the BBC, Atul Gawande – renowned surgeon and author – describes the story of a three-year-old Austrian girl who been out for a walk with her parents when she’d fallen through the ice covering a fishpond. A parent’s worst nightmare – they’d lost sight of her for just a few seconds and the next thing they knew she was out on the surface of this icy fishpond and then fell through the ice and was gone.
The parents ran and jumped in after her, but couldn’t find her. It took thirty minutes before they finally felt a limb at the bottom of the pond and pulled her up to the surface.
Thirty minutes, under the ice, without breathing.
Gawande goes on to describe the amazing story of how this girl’s life was saved. How the parents were instructed to do CPR. How the helicopter came to retrieve her. How the hospital took her straight into theatre. How they cut through her femoral artery and used a heart lung bypass machine to start warming her up. How they plugged an extracorporeal membrame oxygenator directly into her heart to help oxygenate her blood because her lungs were full with pond water and debris.
On and on Gawande describes the steps this community hospital in the Alps took to bring this little girl back to life, one organ at a time. Her heart, her lungs, her kidneys, her liver, her gut. And then how, one day, she simply woke up.
And two weeks after they brought her in by helicopter, she was allowed to go home.
Though at this point, her journey was by no means over. She had paralysis in her right leg and arm and severely slurred speech. But after two years of extensive physical and educational therapy they brought her back into the hospital for tests and found that her physical strength had completely recovered and her psychological capabilities were exactly where they should be for a girl of her age.
So how did a small community hospital in the Alps create a system that could take this young girl, who had not drawn breath for thirty minutes, and bring her back to life?
It started with one doctor – Markus Thalmann in Klangenfurt, Austria – who was convinced that they could save the dozens of people who drowned or were caught in avalanches every year. And so he looked at all the failures they’d had and realised that the problem was a matter of speed and timing. To make this work, they needed to have all the right people and all the right equipment ready in the right place at the right time and in the right order.
So they created a checklist that detailed everything and everyone that was needed, and the order they were needed in, to make sure the people, the rooms and the equipment that was required would be available at the right point in the process. And they gave this checklist to the person with the least power in the system – the telephone operator at the hospital – who became responsible for activating the process.
And that little girl who fell through the ice was their first survivor.
So what could we learn from this story?
How many times have you implemented a solution with a client and either the solution hasn't been exactly what the client was expecting or the implementation didn't run smoothly and/or was delayed?
Fortunately, in our world, we tend not to be dealing with life or death situations. But is that an excuse for not doing everything we can to avoid these problems?
‘Software is complicated,’ people say. ‘The client’s requirements are complicated,’ people say. ‘There are lots of complicated stakeholder relationships,’ people say.
Well, bringing someone back to life who hasn't drawn breath for thirty minutes is pretty complicated too.
What we need in the software world, just like that hospital in the Alps needed, is discipline.
What’s worked well for us at Hollaroo is effectively doing the same thing as that hospital. We've created a detailed checklist of every action that needs to be taken, every conversation that needs to be had with the client, every decision that needs to be made, at every stage both pre- and post- implementation. And then documenting the date and time that each of these actions were taken, each conversation happened, each decision was made, and by whom.
And by having this discipline, and knowing that it works, not only do we make fewer mistakes, but we build greater trust with our clients. It frees us up to understand our clients’ needs more deeply and gives us and our clients’ the courage to try out new things and to explore new avenues of possibilities in ways that were never available to us before.
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