Brent James is one of my new heroes. He’s a physician, a researcher, and the chief quality officer of Intermountain Healthcare’s Institute for Health Care Delivery Research.
We had a very inspiring telephone conversation this afternoon, about whether the lessons learned from evidence-based medicine could be applied to nonprofits that are seeking to manage their outcomes. We also swapped some stories and jokes about the ongoing struggle to document a causal relationship between what a health care organization (or a social service agency, or an arts group, or an environmental coalition, for that matter) does and what the organization’s stated aims are. In fact, documenting that an organization is doing more good than harm, and less harm than doing nothing at all, continues to be a perplexing problem. The truth may be less than obvious – in fact, it may be completely counter-intuitive.
In this phone conversation, we also waded into deep epistemological waters, reflecting on how we know we have succeeded, and also on the disturbing gap between efficacy and effectiveness.
It’s not merely a philosophical challenge, but a political one, to understand where the power lies to define success and to set the standards of proof.
I doubt that this is what William James (no relation to Brent, as far as I know) had in mind when he referred to success as “the bitch-goddess,” but there’s no doubt that defining, measuring, and reporting on one’s programmatic success is a bitch for any nonprofit professional with intellectual and professional integrity. It’s both difficult and urgent.
What particularly struck me during my conversation with Brent was his remark about Intermountain Healthcare:
“We count our successes in lives.”
On the surface, that approach to counting successes seems simple and dramatic. The lives of patients are on the line. They either live or die, with the help of Intermountain Healthcare. But it’s really a very intricate question, once we start asking whether Intermountain’s contribution is a positive one, enabling the patients to live the lives and die the deaths that are congruent with their wishes and values.
These questions are very poignant for me, and not just because I’m cancer patient myself, and not just because yesterday I attended the funeral of a revered colleague and friend who died very unexpectedly. These questions hit me where I live professionally as well, because earlier this week, I met with the staff of a fantastic nonprofit that is striving to do programmatic outcomes measurement, and is faced with questions about how to define success in a way that can be empirically confirmed or disconfirmed. Their mission states that they will help their clients excel in a specific industry and in their personal lives. They have a coherent theory of change, and virtually all of their criteria of professional and personal success are quantifiable. Their goals are bold but not vague. (This is a dream organization for anyone interested in outcomes management, not to mention that the staff members are smart and charming.) However, it’s not entirely clear yet whether the goals that add up to success for each client are determined solely by the staff or by the client or some combination thereof. I see it as a huge issue, not just on an operational level, but on a philosophical one; it’s the difference between self-determination and paternalism. I applaud this organization’s staff for their willingness to explore the question.
When Brent talked about counting successes in terms of lives, I thought about this nonprofit organization, which defines its mission in terms of professional and personal success for its clients. The staff members of that organization, like so many nonprofit professionals, are ultimately counting their successes in lives, though perhaps not as obviously as health care providers do. Surgeons receive high pay and prestige for keeping cancer patients alive and well – for the most part, they fully deserve it. But let’s also count the successes of the organization that helps a substantial number of people win jobs that offer a living wage and health insurance, along with other benefits such as G.E.D.s, citizenship, proficiency in English, home ownership, paid vacations, and college educations for the workers’ children. Nonprofit professionals who can deliver that are also my heroes, right up there with Brent James. While we’re holding them to high standards of proof of success, I hope that we can find a way to offer them the high pay and prestige that we already grant to the medical profession.