1. Agile – Lessons Learnt from Emergency Medicine Management and the Way Forward
Regeena Pereira, Sujith N. Rai, Suchitra Joyce Bontha
Scope and Objective: System and process centric methodology often results in over commitment which
becomes burdened with unexpected and emergency tasks. Deadlines are hampered with improper
definitions of ‘done’ and maintaining quality still poses a gap in number of Agile units. We examined time
tested processes that have shown unfaltering success in hospitals – the emergency department (ED).
Result: Emergency Agile management in many ways incorporates the flow in the ED. No queue, minimal
wait time, clear lanes and seamless movement, backup and short turn-around time (STAT). Triage refers
to a sorting of patients according to their need for emergency medical attention – immediate, immediate
but not urgent and not urgent, similar to categorization of stories to be prioritized on a need basis. This
calls for short iterations to mark movement, reduce queues and absorb the next-in-line. Hospitals with an
ED are always equipped with backup benches to keep with the committed STAT rules. Advocating of pair
programming in Agile methodology provides scope for on-time delivery. An emergency in the ED gets a
quick, yet seamless passage through all the services in the healthcare facility. Cluster of cases are
analyzed for root cause for medical management for preparedness for new cases in this category, similar
to emergency lanes handled in Agile processes.
Business Value and Key Differentiator: Agile methodologies and their practical benefits are best tested
in emergencies, thus enhancing business value with on-time delivery, maintaining quality, meeting client
requirements and responding to change. Comparing emergency to the real-time ED in hospitals attests to
planning and improvising current methods.
Keywords: Agile Emergency Management, Emergency Medicine, Triage, Root Cause Analysis
Introduction: Hospitals, by virtue of nature are habitually plagued with queues and consequently delays,
which in turn leads to dissatisfaction and compromise in care, particularly acute care. The test of smooth
operational flow in healthcare settings is highly evident in the ED as the impact is most palpable here.
Obstacles in the ED become massive road blocks, often a hindrance to the rest of the flow through the
hospital. Common deterrents include delay or lack of adequate patient information, errors in patient
details, inefficiency or lapse in information transmission and faulty flow of material which may compromise
patient safety, cause financial loses and result in regulatory issues, thus directly influencing patient and
staff satisfaction and in turn the hospital itself. Hospitals are therefore increasingly challenged to address
service and quality with respect to emergency care, in spite of getting busier by the day. With time and
after facing innumerable pitfalls, EDs have leveraged on to methods that permit rapid and easy
movement, and therefore, complex and often chaotic as they may be, EDs continue to positively
contribute to a number of significant features of the hospital including patient and employee satisfaction,
patient safety, risk reduction, evidence based outcomes, and profitability. The present day ED represents
performance, quality, safety, and service, providing healthcare systems a substantial service advantage
and competitive edge. On the other hand, while technology supports healthcare in adapting to changing
2. environments of automation, instantaneous responsiveness, clinical decision-making, healthcare delivery
and administration with improved quality and adherence to compliance; information technology (IT) units
could do with a few lessons from ED workflows. Agile methodologies, practiced widely in the IT industry
offer solutions to a number of workflow challenges by means of identifying limitations in existing systems,
use of generic development tools, increased transparency, and enhanced collaboration between working
teams, product owners and end-users. The impetus is on good delivery turnaround time without
compromise on quality and consistency in the end product. The recent 2013, 7
Annual State of Agile
Development Survey by Versionone has demonstrated a significant increase in the agile momentum, with
83% of projects currently going Agile compared to 59% in the last year. However, the bottleneck in such
situations is that defect fixing teams may not possess adequate insight into end user needs. System and
process centric methodology result in over commitment which may become heavily burdened when
unexpected and emergency tasks take priority. Naturally, deadlines are hampered with improper
definitions of ‘done’ or completed and maintaining quality standards begin to pose a gap. Agile units if not
adequately equipped to handle emergencies crumble under pressure and sacrifice quality while trying to
In the present paper, we draw comparisons to the ED in hospitals that through time has evolved into a
resolute practice. We draw parallels to triage management, back-up benches, clear-lane policies or short
turnaround time and root cause analysis, lessons that can be learnt from ED units in hospitals, and a way
forward for Agile units.
Emergency Medicine – a Functional Formula: Dealing with emergencies has been rooted since times
when the ‘good Samaritan’ bound the injured traveler’s wounds with oil and placed him in reliable care.
When disasters occur and create emergencies, the ability to respond to the uncontrolled event with
maximum speed and coordination of resources can save billions of dollars in damages and prevent
unnecessary loss of life, the reason emergency medicine (EM) today stands as a distinct medical
specialty. Emergency Medical Services (EMS) as a specialization dates back to the 1860s French
Revolution when speeding carriages of the French flying artillery scored battlefields rescuing the
wounded, transporting them to centralized field hospitals, thus creating a forerunner to modern EMS.
Though the concept took shape almost a century ago, EM as a specialization is relatively young, formally
designated for about 70 years now. EM and the role of the ED are born to fulfill uninterrupted time
commitment required by physicians and staff to work in increasingly chaotic situations. Over the times,
strategies and recommendations developed to address and improve patient flow descriptive as
emergency care of patients admitting at EDs requiring increased support from the hospital, including the
same level of services from radiology, laboratory, pharmacy, and ancillary services inclusive if not further
than patients receiving inpatient or acute care. ED workforces are appropriately trained in managing
critical care patients. ED teams comprise of multidisciplinary teams encompassing of the hospital-wide
patient flow team, who operate on set ED protocols, prepared to identify problems and barriers, to
implement an ED flow. Few commonly employed ED strategies include engaging hospitalists or
intensivists to manage admitted patients in the emergency department, increased nursing and physician
staffing at various levels, creation of admissions unit or triage units adjacent to the EDs, and use of
technology to optimize workflows.
3. Agile Emergency Management: Agile management during emergencies is a direct consequence of
experiences due to disasters that may have resulted in long-term cleanup and remediation. Handling an
emergency in Agile units comes under the auspices of delivering “regular” work alongside prioritizing and
handling the emergency situation itself. Emergency Agile management in many ways incorporates the
flow and process that takes place in the ED of a healthcare setting - triage in order to prioritize, no queue,
minimal wait time, clear lanes and seamless movement, backup and short turnaround time (STAT). The
very goal of Agile is the ability to reasonably absorb uncertainty, thereby striking a balance between
robustness and speed that aligns with the Agile manifesto, ‘Individuals and interactions over processes
and tools’; ‘Working software over comprehensive documentation’; ’Customer collaboration over contract
negotiation’; and ‘Responding to change over following a plan’.
Triage – Pick, Perform and Reject: Triage in EM refers to sorting of the injured or sick according to their
need for emergency medical attention. The conventional EM classification of triage is immediate,
immediate but not urgent and not urgent. A similar approach of categorization is employed by Agile bug
fixing units to prioritize a list of defects or tasks. However, the fundamental problem in Agile units rises in
prioritization primarily due to constantly changing client requirements, varied nature of defects, and the
magnitude of sheer numbers. As new issues or defects get added on, the older problems refuse to
disappear from the list. Therefore triage as the first step, plays a critical role in sorting, prioritizing, picking
and rejecting issues to be fixed by the team. Easier said, bug triage decisions in Agile, often involve a
number of conversations around the severity and priority of each bug, in spite of which most of the
measures employed in prioritizing leave loose ends and improper ranking. Customarily triage efforts
revolve around factors that influence the priority rather task of prioritizing itself. Agile teams are known to
employ risk matrix or probability and impact matrix, to address prioritization. Probability and impact act as
qualitative proxy measures enabling effective and focused client conversations and eventual paves a way
to appropriate classification of tasks. Judicious triage allows for shorter, yet comfortable iterations to
absorb in-line issues as quickly as possible. Triaging, similar to the way an ED functions allows for instant
assessment of the case in order to categorize, therefore permitting bug fixing Agile units to bundle similar
stories that can be resolved simultaneously. Triaging holds the key to streamlined flow in emergency
situations. Imagine the consequences of improper triage of battle victims. It would leave a lot of critical
victims in need of care while ambulatory or victims with minor injury would walk in for care. Naturally, not
in the least serving the purpose of ED, where those in absolute need are given priority care. Usually an
admissions “gatekeeper” in the emergency department ensures appropriate hospital admissions. Yet
another factor that contributes to emergency management are emergency swim lanes in Agile units that
may be restricted to a minimum number, thus preventing overload and revisiting of precision prioritization
and prioritization criteria, much like the bed strength in hospital emergency units which are limited,
allowing for concentrated medical efforts and smooth flow through the various facilities in the healthcare
Clear Lanes for Uninterrupted Movement: An emergency case from the ED gets a thoroughfare across
all the services in the healthcare facility, be it laboratory, radiology, surgery or admission. Likewise
4. clearing lanes in emergency swim lanes with an exclusive work in progress limit in Agile teams frees
unnecessary impediments, offers seamless and rapid movement, and focused remedial measures on
good turn-around time. A working archetype for emergency Agile practices is the ambulance blowing a
whistle getting a freeway through busy roads including traffic signals achieving the best point-to-point
movement in regular traffic conditions. Clear lanes may simply imply standing back to make way and
avoiding being a hindrance, and in a few cases, it may mean lending a hand to remove an impending
hurdle or even probable foreseen obstacles, essentially allotting additional resources, reducing wait time,
and prioritizing. Like natural disasters and medical emergencies, an emergency by definition itself comes
with little or often no notice, and therefore Agile teams working under such conditions should be primed
for preparedness to take up an emergency with a principal focus of creating a freeway and directing
effective resources should an emergency occur. A number of factors inclusive but not limiting are
severity, dependence, and numbers of impacted clients which contribute to switching of lanes from
emergency to regular and vice versa. Based on definitions, a specified emergency protocol in place
permits efficient transition across swim lanes.
Buffer for Emergencies: Hospitals with an ED are adequately equipped particularly for diagnostics,
acute care facilities and operation theatres. Backups in diagnostics include laboratory and radiology
service resources that are available to take up unexpected emergency testing or equipment breakdown or
maintenance in order to stay committed to the turnaround time (TAT) – time taken from sample
registration to result reporting. In diagnostic services, TAT is an important factor that dictates the
efficiency of laboratory service and is often used as a key performance indicator of laboratory and
radiology performance. Compressing TAT to the maximum by eliminating delays and avoidable time lags,
without compromising on quality to accommodate emergency and acute care needs define STAT
reporting. A combination of ample backup resource allotment and predefined STAT protocols ensures
smooth ED operations. Accounting for emergencies, Agile teams advocate pair programming, an Agile
methodology that provides scope for on-time delivery. Buffers are used to manage the risk of estimation
overruns that would threaten the success of the project, and are used in all software development
planning approaches to one extent or another. Feature buffer and schedule buffer primarily postulate
backup for such situations. Feature buffer prioritizes features in order to ensure mandatory items are
positioned high on the list, while furnishing enough flexibility to ensure these unexpected emergencies
prevent jeopardizing the project as a whole. Iteration planning compromising of no more than 70% of the
planned effort for a project for ‘must have’ provides space to accommodate unexpected tasks rising from
emergencies. Schedule buffer is used to reflect and accommodate uncertainty at the project level.
Schedule buffer maintaining about half the time of the safety time taken out, results in a project that is
planned to be 75% of a traditional project network.
Analysis - Trends and Root Cause: While the unique role of the ED tags it as the safety net of the
health care system, crowding sometimes becomes inevitable and is considered an enormous crisis.
Crowding poses strain on this safety net resulting in a breakdown in the very purpose of ED. EDs work
around diverse methods to avoid disruption including input-throughput-output models, efficient triaging,
and root cause and trend analysis. Analysis of presenting symptoms especially in epidemics influences
5. clinical decision making. The service industry is not new to root cause analysis and Agile practitioners
advocate analysis of root cause for better turnaround time and resourceful effort. Mapping ED trends
strengthens the ED flow established in elderly patients comprising of nearly 10% to 30% of ED
admissions, acute myocardial infarction and sepsis. Bug fixing teams fostering defect analysis benefit
from the advantage ‘cure at the root’ instead of patching individual defects. Deliberating on the defect root
cause or trends pertaining to the team’s delivery and efforts stimulates successful triage and prioritization,
subsequently inducing appropriate implementation along with appropriate prevention strategies.
Conclusion: Agile methodology emphasizes flexibility, informal cooperation and time driven deliveries.
Various industries have adapted and found success in these methodologies. However, the challenge
rests in managing and delivering in emergencies. Agile emergency methodologies employ project
management principles on a highly advanced platform in order to overcome the challenges that come
with the unpredictable. Like health related emergencies that come without warning requiring immediate
medical attention, bug fixing teams are often bombarded with emergencies. It therefore becomes
imperative for such teams to adopt practices that spell success on the lines of appropriate resolutions,
commitment to timelines, resource management, preservation of quality and process compliance.
Accommodating emergencies is never at the risk of overlooking or delaying ‘regular’ defect fixing and
therefore emergencies necessitates an independent process and flow. Emergency Agile management
should ensure responding teams are well equipped with the capability and capacity, key being careful
planning providing responders with clear direction and focus. Learning from emergency medicine
management, the way forward for Agile teams is preparedness. Factors that significantly contribute to
managing emergencies include triage and prioritization, short iterations to absorb in line defects, speedy
movement through clear lanes by reduction in wait time and unnecessary processes, pair programming in
order to shift resources in time of need, and root cause analysis. Focused and concentrated efforts
therefore augment business value with on-time delivery, maintaining quality standards and meeting client
P.M. Carter, J.S. Desmond, C. Akanbobnaab, R.A. Oteng, S. Rominski, W.G. Barsan and R.
Cunningham, “Optimizing Clinical Operations as part of a Global Emergency Medicine Initiative in
Kumasi, Ghana: Application of Lean Manufacturing Principals to Low Resource Health Systems
Department of Emergency”, Academic Emergency Medicine, 2012, 19, pp. 338-347.
A. Cockburn, “Using Both Incremental and Iterative Development”, Journal of Defense Software
Engineering, 2008, pp.27-30.
Cohn, M., Agile Estimating and Planning, Prentice Hall, New Jersey, USA, 2005.
L. Craig, and V. Basili, “Iterative and Incremental Development: A Brief History”, Computer, 2003, 36, pp.
6. M. Hoogendoorn, C.M Jonker, V. Popova, A. Sharpaskykh and L. Xu, “ Formal Modelling and Comparing
of Disaster Plans. (2005). In: Carle, B., and Walle, B. van de, (eds.)”, Proceedings of the Second
International Conference on Information Systems for Crisis Response and Management ISCRAM '05, pp.
O. Linet and E.B.K. Ediz, “Emergency logistics planning in natural disasters”, Annals of Operations
Research, 2004,129, pp. 217-245.
A. MacCormack, “Product-Development Practices That Work”, MIT Sloan Management Reviews, 2001,
42, pp. 75-84.
C.E. Matthews, “Agile practices in embedded systems”, Proceedings of the compilation of the co-located
workshops on DSM'11, TMC'11, AGERE!'11, AOOPES'11, NEAT'11, & VMIL'11, 2011,11, pp. 249-250.
T. Schümmer, and S. Lukosch, “Understanding Tools and Practices for Distributed Pair Programming”,
Journal of Universal Computer Science, 2009,15, pp.3101–3125.
J. Shore and S. Warden, The art of agile development, O'Reilly, California, USA, 2007.
J. Smith and T. Haile-Mariam, “Priorities in global emergency medicine development”, Journal of
Emergency Medicine Clinical North America, 2005, 23, pp.11–29.
Version one, 7th-Annual-State-of-Agile-Development-Survey, 2013. http://www.versionone.com/pdf/7th-
7. Author’s Profile:
1. Ms. Regeena Pereira, PMP
Team Lead, Technical Project Manager with 12 years of experience
Current Organization: Cerner Corporation
2. Mr. Sujith N. Rai
Software Engineer with 3 years of experience in Avionics and Healthcare IT.
Current Organization: Cerner Corporation
3. Dr. Suchitra Joyce Bontha, M.Sc. (Medical Microbiology), Ph.D.
Sr. Requirements Analyst with 15 years of experience in Healthcare and one year of experience
Current Organization: Cerner Corporation