Value-Based Delivery4

Agility in an Austere Environment

Battlefield to Business Agility

Agility in an Austere Environment: Battlefield to Business Agility | Matt Spruce

Matt Spruce

April 21, 2022


From humble beginnings as a medic in a small unit, right through to becoming the senior advisor at a deployable field hospital, the priority is the “man on the stretcher”. The patient represents a common goal, it brings the team together, pushing in the same direction to save life. There are not many situations where the pressure is higher. As I have progressed through the ranks, I have ensured that I have served my team, removing impediments to allow them to flourish and deliver excellence. Giving not only ownership of the end goal, but also ownership of the process to achieve that goal has been key to my success within the military.

About Matt

I have served in the British Army for over 23 years and had the opportunity to be part of a number of high performing teams who have had to deliver excellence, often in demanding and complex situations. I have built up significant experience in coaching, developing, leading and empowering multiple cross-functional teams to self-organise effectively, often in highly pressurised and reactive environments.

From humble beginnings as a medic in a small unit, right through to becoming the senior advisor at a deployable field hospital, the priority is the “man on the stretcher”. The patient represents a common goal, it brings the team together, pushing in the same direction to save life. There are not many situations where the pressure higher. As I have progressed through the ranks, I have ensured that I have served my team, removing impediments to allow them to flourish and deliver excellence. Giving not only ownership of the end goal, but also ownership of the process to achieve that goal has been key to my success within the military.

I have followed a set of values and standards in my career, the one that sticks out is integrity, the quality of being honest and having strong moral principles. This will bring the team closer; they will have a trust and bond that will promote positive conflict, not be afraid to voice an opinion. During a difficult time, when I was working in one of the UK’s busiest trauma hospitals, I established a retrospective feedback program that allowed for all Trauma team members to feed back after difficult cases. This reflective get together allowed everyone to have a voice, regardless of position, speciality, or seniority. The outcome of the retro’s allowed for tweaks in the process which undoubtedly improved patient care and enhanced the performance of the team.

In the last 23 years of building high performing teams in austere environments, against time pressures using life critical systems, I have been building capability and delivering value early. Inspection and adaption have been key throughout my career, allowing me to set the pace and coach the team to maximise their potential. Having worked Globally with multinational and multifunctional teams, I have created sustainable capability, that can be maintained and utilised by the User. I am trained to respond to change. Environment and people are what is important to allow teams to achieve results consistently. I know I can have a positive effect on both.

I am a keen sportsman and although in the twilight years of my “Sporting” career, I still play and coach football at a competitive level. I enjoy coffee, mainly drinking it but I have the intention to roast and blend my own. I enjoy a challenge and often put that to good use by raising money for various charities. I would like to say I enjoy reading but I am more of a “collector” of books, at last count I had 67 books on the “Backlog”.

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My name is Matt Spruce. As Stuart said, I'm currently an agile coach with Capgemini. In my role, I coach Agility. But not only that, I instruct and train other coaches, as I've been through the ICAgile process. And this is somewhere which is so many miles away from where I cut my teeth in the world of work.

What I'm going to look at is improving patient care. How agility has done that for me. The journey I've been on, from being a combat medic, working on the front line, to being where I am now as an agile coach. And some of the challenges I faced.

Firstly, I hugely apologize that I'm remote. I was all set. My ticket, my flights were booked. I was looking forward to walking around there this evening and swapping my tickets. I hopefully go over that golden snitch of the Harry Potter theater tickets. But COVID had other ideas.

So, I failed a COVID test. I've only got mild symptoms, thank God. And thankfully Evan and the team have allowed me to pivot to still deliver the presentation. So maybe next year I'll hopefully be able to share the stage with incredible speakers and maybe even the room.

So, I'm going to look at my journey. Agile by necessity, and my experience of being involved with that. Some leadership challenges that I've had and I've experienced. And also, I'm going to look at retrospectives. And where I’ve introduced retrospectives in my role prior to leaving the military and what a difference they made to patient care. But first of all, I have a quote.All good presentations have quotes. And this is one that I kind of live by. 

The lady you're looking at is Rear Admiral Grace Hopper. Not only is she a thought leader and a spearhead of women in the military. But also, she's an incredible ambassador for women in software. And what she came up with is a quote; "it's easier to ask forgiveness then to get permission in the first place".

And what she was talking about was the amount of hierarchical decisions that needed to be made before change was impacted in the global organization. Now, she's not saying just do something reckless. She's saying do the right thing within the organization, whether or not they know it, thinking about the people first. And this is something I really hold dear to me. Hold close to my heart and something I've followed throughout my military career. And just a little bit about that.

So, I served for 23 years in the British Army. And from humble beginnings as a medic in a small unit, right through to becoming the senior advisor at a Deployable Field Hospital. The priority has always been the patient. It represents a common goal. It brings the team together, and it really pushes that same direction for us to save life. I would argue there's not many situations where the pressure is higher.

And as I progressed through the ranks, I've  ensured that I've always served my team. I'm very passionate about leadership, passionate about my team, passionate about the people I work with. I give them not only ownership of the goal, but ownership of the process.

Working in a clinical environment, you're surrounded by good people who know what they're doing and who am I to tell them what to do? My military career has seen me deploy all over the world, including peacekeeping tours in Eastern Europe and the Balkans, through working in Iraq and Afghanistan on many combat tours. Including working in the busiest trauma hospital in the world at Camp Bastion. And that will be a flavor for one of the stories I talk about a little bit later.

Throughout my career, I progressed as a medic. I found myself in managerial positions and given projects to deal with and to deliver. And to be honest, we weren't given much training in how to deliver a project. We weren't given much information and much methodologies. So  I went and found one myself.

I'm fortunate enough that my brother introduced me. He works in the agile space, and he introduced me to Scrum. We had a conversation, we had a glass of wine. He said, you should try using this. So I was a coach anyway. And now I found myself trying to coach my team into learning new skills in this non-agile organization. A very hierarchical organization, as you can imagine.

Now, it's not in the software space. For me, it was in the training development space. Developing clinical training. Clinical governance has sharp rules. It has a difficult line to hit. And this waterfall method of project management just didn't work for me. Clinical guidelines, they change regularly. And it's vital to ensure that what I was delivering, and the training we were developing, would meet the need. It needed to be agile. It needed to work. It needed to work better than conventional project management.

Now, the team I was working with was seasoned professionals who have been involved in delivering medical training for many years. And they were saying, what is this? Why should we learn this? What's wrong with the way we've been doing it for years and all those old adages? And I tried to convince them.

I tried to talk them through. I tried to put some slides together. But the biggest thing that they struggled to align to was value. What value? What is value? We're not a financially profit organization. Where are we defining value? So I took an opportunity to speak to the team and said, you tell me what value is. Let's work this out. Let's work this out as a team collectively. We decided that value and the focus for all of the work we would do would be the man on the stretcher. 

So every bit of work we did, development of training, development of equipment, development of processes. It had to have a positive effect on the man on the stretcher. Now, if it did that, then we were aligned. If we did that, it meant that we were working together and we were improving process. 

We started creating solutions quicker. We started delivering quality quicker and faster and better. It was fantastic. People around us started wanting a bit of the agile juice that we were drinking in.And we're asking, what is this process you're going through? How are you delivering things quicker? What are these boards? Why are there post-its? Why does it look so messy in here? And the rest of it. It got me thinking. When have I been involved in an agile process before? What's been something tangible? This can't be it. This can't be me introducing this.

And then I got thinking about the deployments I've done before and the work I've done before. And I started thinking about the combat application tourniquet. Now, the slide you're looking at there. The top tourniquet is what they call the Samway Anchor Tourniquet. It's a tourniquet that was developed in the late, sort of 1800s. And basically was used, focused, and was used as a bit of equipment in the first and Second World War. The last one that was made was in 1950.

Now, when I joined the army in April 98, I deployed to Kosovo. And this bit of equipment, the Samway Anchor Tourniquet, was issued to me to use, and I used it. My first casualty on operations was a young lady who stood on a legacy landmine. Bit of equipment I needed to use was a Samway Anchor Tourniquet. Rubber, 20 years old, a nickel plated hook, not really fit for purpose. But, it's what we've always done.And tourniquets were traditionally bad. They've been discouraged since World War II to be honest. Many soldiers suffered amputations due to the tourniquets that were on for too long. They just didn't really transport very well.

And studies of experience showed that 7% to 10% of battlefield deaths in Vietnam and Somalia could actually have been stopped with the correct application of a tourniquet. Now you fast forward five years to the wars in Iraq and Afghanistan. And now I'm deployed to Iraq and we’ve got the Samway Anchor Tourniquet. But we're setting, we're getting casualties who are suffering injuries, that the tourniquet's not working. 

And all of a sudden the war in Iraq and Afghanistan started giving us this real-time evidence-based process improvement. Fresh data showing us that we need to improve. And as you can see, the picture underneath that, it's a Combat Application Tourniquet. It's essentially a piece of material and Velcro with a little bit of plastic and a buckle.

Now, this was developed quickly and brought into service quickly. It could be applied one handed, it could be applied by the individual. And the feedback loop was incredible. We got the information back to the people developing the tourniquet, saying, this is working, this isn't working. So they changed it again. They would iterate. They would change and we would get more into service. This is cheaply produced. As I say, it's a piece of Velcro with a little bit of plastic on it.

But all of a sudden, we were dealing with casualties who were surviving nonsurvivable injuries due to this small bit of equipment. The feedback loops were incredible. And the old feedback loops looked something like this. When we were deployed on operational tour, you were away for six months. And at the end of the tour you would have the feedback. You would have an after action review. You discuss what you've done on your tour, what went well, what didn't go well? Great. You'd high five and you thank them for taking over all your kit while you flew back, back to the UK. 

We would promote what we've done well and we would sometimes hide what we didn't do well, to be honest. But our feedback loop changed. It changed so that we changed the cycle. We needed to reduce the time. We needed to focus on improvements and patient outcome. As I talked about earlier on that value.

There was an opportunity for innovation. There was a role established to coordinate this feedback. Where we could look at the patients who were coming in, look at the injuries, look at the application of tourniquet, and feed it straight back to the UK. And with advances in technology, this went from every six months to every month to every week. Where the hospital, dealing with the patients, could video call back to the UK, where we were delivering the training now, and improve that process. So that we can make sure that they were getting applied properly.

That patients were surviving these nonsurvivable injuries. The critical care for combat trauma patients has been transformed over the last year. To a point where it's adopted in the UK. Our patient pathway is no longer linear. We've iterated the whole process to deliver better care earlier. And this was my exposure to agility. Agility, by necessity. The importance of a feedback loop. It was happening, I was involved in it, and I didn't even realize.

Next thing I want to look at is leadership. And one of the lessons I learned in leadership. Now, as part of a treatment team, when you've got a medical facility, a hospital, they're designed on operations to treat the coalition troops. Our US friends, the UK working together, to provide a clinical capability. You're not there to provide hospital care for the local nationals. Now, I was the leader of a small team and we were responsible to go and set up a triage point. Essentially making decisions where we would take local nationals and, if they would meet the medical rules of eligibility, they would come into the facility. 

Now, the medical rules of eligibility were legal. This is important stuff. The medical rules of eligibility are quite simple. It's life, limb, or eye. If they are suffering injuries with life, limb, or eye, then they can be admitted into the facility. So I was with a small team, a young team, many on the first operational tour. There's been an incident in Basra and we were set up at the front of the camp. And our acceptance criteria, if you want, for patients to go through, was those medical rules of eligibility.

We were turning away countless amount of local nationals, some with quite severe injuries, but none that sacrificed their life, limb, or eye. I could feel the morale in the team lowering. Why do we train as medics Why were we here if we couldn’t deliver clinical care? And then an incident happened.

A girl was brought to the gate. She was around seven or eight years old and she had some minor abrasions, and some burns. The story which was given to us through our interpreter was that she was involved in an incident in a car where both of her parents died. The person carrying this girl to us was just a friend of the family.

I could see the morale in my team's face lower. I could feel it. Because we knew that she didn't meet the medical rules of eligibility. But I thought back now to Grace Hopper. I'll beg forgiveness and we submitted her. We admitted her into the facility. She went through.I could see the morale of my team raised because they thought “brilliant, this is what we're here to do.” "This young girl got nobody and we’re going to do something about it."

So she was taken into the hospital. Shortly after we collapsed  the exchange point, returned to the hospital base, and my team were dispersed to go and have a bit of downtime. And I was severely reprimanded. I was the leader. I made the decision. It was against the medical rules of eligibility. I took it on the shoulders. Severely reprimanded. My team never knew. Still to this day, don't know that I was reprimanded. They went away with one of those thoughts, those memories, that they'll always have, that they did a good thing. And I thought that was important.

What I learned from that was when people make decisions under pressure, it's the right decision, and you support it. Because it's better to ask forgiveness later than sometimes to ask in the first place. I learned a lot from that leader. A lot from that person who gave me the reprimand, that I made sure that I would never do that again. Never. I've never put anyone in that situation. Where they made a decision under the pressure and felt that it was wrong.

The next thing I want to look at is retrospectives. Now, retrospectives. By this point in my career, I was quite senior. I was in the hospital in Afghanistan. And I was responsible for the Emergency Department. Now, what would happen, usually in a clinical setting, is the most senior person makes the decisions. That's the consultant level. And rightly so clinically, they're superb.

Camp Bastion was the busiest trauma hospital in the world, with the best consultants, the best clinicians across the US, UK, and Danish Army. They were incredible. And after we had a number of cases. So once a patient came in, they were treated by 15/16 people in the trauma team. And at the end, the consultant would say; "this is what went well,  this is what didn't go well, this is what we can do better next time.” I didn't like this.

There were still mistakes getting made. Small mistakes, not clinically, but process wise. So I changed this and said, Why don't we try giving everyone a voice. Give everyone 20 seconds, just to say one thing that went well, one thing that didn't. Now, I've used a painting. I've got no gory pictures. I'm not going to do that to anyone. But there was 15/16 people in the team. And we would find that the mistakes that were getting made. Well, the scribe, the lowest possible rank, not clinical,  writing the notes down, was noticing there was mistakes. Because there's too much noise. So what they suggested was, "why don't we have big whiteboards, with the free side to the patient?"

So the nurses doing the work, and just write on the whiteboards, and I can just read it then. I don't even have to confuse you. Brilliant, let's implement that. And the next thing was the runners. Every patient that came to hospital needed bloods taken and they needed testing. But, people were handwriting on bottles. What happened in the fog of war, if you want, the handwriting would be too poor, wouldn't be able to be read. And tests would need to be done again and again and again.

So one of the runners, he was a driver, an ambulance driver who wasn't on shift said, "why don't we produce a bank of stickers, all the same stickers?” And then as a patient comes in, we can use a sticker on a bottle, and they're all have that unique number and we can align it to the patient.

This was low cost. We had consultants, hundreds of years worth of experience in the clinical space. And it was an ambulance driver on his first operational tour who unlocked the key to better process. Everyone has a voice, and it's important. And this is something I learned. Involved in a non agile organization, but absorbing agile.

So what have I learned along the way? Well, I've been a part of a number of high performing teams. Okay, your team are the most important. Inspection and adaption has been throughout my career, allowing me to set the pace and coach the team to maximize potential. You've got to be credible and you’ve got to listen to your team. Your team are the most important thing. And please, please, align your teams to value. And I've took this into business, took this into coaching, took this into working for CapGemini.

You've got to align people to value. And that's one of the priorities whenever I go to a client, whenever I speak to anyone, what's the value? What's the alignment? What are we focusing on here? 

That concludes my presentation. Again, I'm hugely honored and humbled to have these opportunities to speak to you and with the rest of the two incredible speakers before me. I'm happy to take questions, I guess and I'll do my best to answer them. But if I can’t, I will certainly get back to you.

So, thank you so much for the opportunity to speak at this incredible conference. I wish I was there with you. But yeah, maybe next year. Thank you.

Awesome. Thank you, my friend.

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