Tag Archives: outcomes management

“Forgive and remember”

Forgive and remember

File this under “lessons about failure that the nonprofit sector can learn from medical sociology.”

Forgive and Remember: Managing Medical Failure, by Charles Bosk, is a classic of medical sociology, an analysis of how coping with failure is built into the training that surgeons receive in hospital rounds, mobidity and mortality conferences, and other settings.

Please note that I am not claiming that surgeons themselves have a lot to teach us about dealing with failure, because my experience is that while their sub-culture does have rituals and protocols that they enact privately, they still have a way to go in transparency and accountability to others.

This has been my experience in three instances of major surgery:

  1. Surgeon did not follow instructions given by the specialist physician managing my condition.  Acknowledgement: Partial.  Apology: No.
  2. Surgeon did not inform me that the tumor to be removed might be malignant and require addition surgery until I was under anesthesia. Acknowledgement: Yes, after I complained. Apology: Yes, after I complained.
  3. Surgeon did not respect my request regarding administration of anesthesia:  Acknowledgement: Yes, after I complained. Apology: No.

Not that I am bitter.

But let’s face it:  most of us are highly invested in showing the world that we are skillful, trustworthy, and deserving of whatever prestige is ascribed to us.  As a patient, I naturally blamed the surgeons, not only for their errors in judgement, but for the instances in which they failed to acknowledge or apologize for their mistakes.  As a fellow human being, I completely empathize with their reluctance.  I imagine that that reluctance is more acute among professionals who have to cut people open.  Their work is obscenely invasive but often lifesaving,  and therefore must maintain an impeccably trustworthy reputation.

That’s why Brent James is one of my heroes, along with surgeons and physicians like him who are putting it on the line for evidence-based practice.  There will be no accountability, transparency, or improvement in health care unless successes and failures are accurately documented.  Those results must then be carefully analyzed, made available to the public in appropriate ways, and used to improve their efforts.

As with medicine, so with other mission-based organizations.  We need to track outcomes, acknowledge failures, and then do better.  If it takes a pink feather boa and an amusing ritual for nonprofits to get there, I’m all for it, though I’m not expecting surgeons to adopt the feather boa.

As for the slogan, “forgive and remember,” I think of it as both a spiritual and a practical precept.  We not only need to forgive ourselves and others when we have failed – we also need to bear the lessons of failure in mind.  Both individuals and organizations not only need to keep learning, but to take appropriate action to protect those who are at risk.

I used to work in violence prevention, and for me, one of the most heart-rending aspects of it was the well-documented difficulty in stopping offenders from repeatedly battering their loved ones.  In some cases, they simply didn’t see their behavior as abusive, or their loved ones didn’t see any alternative to accepting abuse.

As I reflect on that today, it drives home very painfully the lesson that we cannot always change others, or even control a specific behavior of theirs.  The old cliche that they “have to really want to change” is true, and it’s also true that not everyone who wants to change can do so. This is the really difficult side of facing failure for nonprofit organizations – in some cases, there may be no alternative to severing ties with individuals or organizations, if the organization is going to face its failure and move on.  It’s going to take more than a pink feather boa, a “joyful funeral,” or a FailFaire to get past that.  When the well-being of vulnerable people is on the line, there are cases where forgiving and remembering is crucial, but it isn’t enough.


Bonus item:

Q:  How many psychotherapists does it take to change a lightbulb?

A:  Only one, but the light bulb really has to want to change.

Adventures in failure (and ritual studies): The “joyful funeral”

Beth Kanter and I are not twins who were separated at birth, but we have some things in common.

So perhaps if we were twins, I wouldn’t be the evil twin (I hope) but the lagging twin.  She’s succeeding at writing in a very engaging and helpful way about failure, and I am definitely benefiting from that.  Thinking about how to acknowledge failure flows very naturally from my current absorption in outcomes management for nonprofit organizations.

Beth recently published a blog article on “Six Ways Nonprofits Learn from Affordable Losses or Little Bets to Improve Impact” that appealed to me greatly, mostly because some the practices described have a ritual component.

I was especially excited when I saw that Beth had included the “Joyful Funeral” custom that was created by Moms Rising.  I had heard rumors of this ritual in nonprofit management circles, but couldn’t remember the details.  Fortunately, Beth’s article includes a cool video, in which she interviews Ashley Boyd about what it really entails.

Now, unlike Beth, I studied sociology of religion as a graduate student, and have a longstanding interest in ritual studies.  Regardless of one’s religious beliefs and affiliation – or lack thereof – it’s easy to see that ritual often has great power in assisting human communities that are confronted by change or loss.

Let’s look at the characteristic stages of a “rite of passage:”

  • Detachment or withdrawal from the status quo
  • Transition
  • Reincorporation into the social group

Likewise, consider a purification ritual, in which the transition in question is from an “unclean” to a “clean” state.

I propose that we think of a joyful funeral as a combination of passage and purification.  The individual or organization has an opportunity to mark the change (which may also be a loss) from a viable initiative to a failure, to acknowledge shortcomings, to mourn, to be supported by the community, and to achieve closure, and to begin the next stage of life.

Many people are left cold by any kind of ritual, and others are put off by the links between elaborate ritual and religious institutions from which they are alienated.  For that reason, I would never argue that a joyful funeral (or any of the other celebrations of failure that Beth describes) should be attempted by everyone.  But for many of us, a ritual can be a comfort, especially if it doesn’t demand that we buy into a dogma or denomination.  A ritual can also be goofy and fun.

I like the idea of building laughter without humiliation into a ritual acknowledgement of failure. It’s less scary and less punitive than a solemn occasion, and better for strengthening ties among the team and making it fun to learn from mistakes.  For this reason, I recommend the “DoSomething PinkBoa FailFest” to beginners in the art of failing and moving on.


Bonus item:  a joke for people who take ritual a little too seriously.

Q:  What’s the difference between a liturgist and a terrorist?

A:  You can negotiate with a terrorist.


 

Why are you always talking about “saving the whales?” (Redux)

This is an article that appeared in my first blog in January 2005.  Many thanks are due to the Wayback Machine, which enabled me to salvage it. 

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11:46AM (EST) on January 20, 2005

Whenever I am speaking or writing on the topic of mission-based technology planning, I seem to end up talking about  “saving the whales.”  Several people have asked me (or teased me) about this, so here are some reasons:

  • I like whales. It’s quite possible that they have forms of language, cognition, and social structure that are as rich as – but completely different from – what humans have developed. For someone with my moderate-progressive values, saving them from extinction seems like an obviously good idea.
  • It sounds like a very straightforward mission, but is actually fraught with complexity and nuance.  I have a sort of fantasy scenario about the disconnect between serious techies and nonprofit professionals.  The techies might be brought in to help a nonprofit organization that exists to save the whales; they get very excited telling the nonprofit team about how they are going to equip all the staff and volunteers of the nonprofit with personal digital assistants (with global positioning systems, naturally) and program them so that the PDAs will start beeping whenever a whale is washed ashore within ten miles of the person with the PDA.  Everyone on staff delves deep into considering whether there’s room in the budget for this exciting but possibly complicated and expensive technology.  Then the Cyber-Yenta does her best to call time-out and remind both the techies and the nonprofit workers that their organization does not actually “save the whales” by going down to the beach with big nets to drag them back into the water.  In fact, what they do is “save the whales” by working for laws and policies that protect the whales.  Can they think of a way that PDAs with GPS would help them do that?  Usually, the answer is no, because legislators and policy-makers won’t consent to being tagged and tracked like wildlife by lobbyists.  In this fantasy scenario, the optimum outcome is that everyone goes back to thinking about technology that actually supports their mission, strategy, and tactics.
  • It’s a great way to introduce the concept of realistic outcomes measurement to a nonprofit organization that is struggling with it.  The introductory question can be:  how many whales do you save a year?  This is actually very difficult to calculate, but is absolutely crucial before moving on to advanced questions such as: how many MORE whales will you save a year with that new technology implementation?

 

Let’s revisit the concept of failure-friendliness

Eight years ago, I wrote a blog article about failure-friendliness in nonprofit technology. It was very much inspired by my friend and colleague, Dan Scharfman. Since Dan died this week, and this is also a week when I have been thinking hard about the obstacles that nonprofit organizations face in tracking their outcomes, it seems appropriate to reprise the article here and now. Having coped with the need for failure-friendliness in nonprofit technology for years, I see that my understanding is still superficial when it comes to the difficulties that nonprofits have in acknowledging programmatic failure. I invite your thoughts on how we can be more transparent about and more open to learning from failure. Meanwhile, special thanks go out to Beth Kanter, for her outstanding blog articles on this topic.

FAIL stamp

Wed 26 Jan 2005 05:41 PM EST

The term “failure-friendly organization” was first introduced to me by a colleague I revere – Dan Scharfman of Baird Associates.

My first impression was that he was an unlikely champion of failure, since Massachusetts is well-supplied with nonprofit organizations that consider the technology services that he has provided to them very successful indeed.

However, many of us in the nonprofit sector have seen the following things happen with major implementations or upgrades:

  • The technology doesn’t work, or doesn’t work nearly as well as it should;
  • The intended users won’t have anything to do with the technology;
  • Major changes in technology in the outside world quickly render the organization’s choices obsolete;
  • Programmatic priorities change, and the technology is all but irrelevant;
  • The organization has not factored in the shocking cost of customizing, tweaking, maintaining, and upgrading the technology.

Although techies vary greatly in their attitudes about projects that don’t work out, we also tend to make tacit assumptions that everyone concerned understands that we are not engaged in an exact science but in an evolving process.

Techies also tend to regard failure as pretty interesting – as a good source of information about what ought to be fixed when Version 97.53.01 of the software is released.  We also enjoy working on cool tools, even if such tools don’t actually deliver the outcomes desired by those who are underwriting the project.  This form of process orientation can be less than endearing to decision-makers in nonprofit organizations.

Oddly enough, nonprofit workers tend to be very good at process orientation when they are on familiar ground.

Sometimes this process orientation is a grim necessity, with governmental agencies strictly mandating, auditing, and enforcing protocols that nonprofits must follow in order to maintain their tax-exempt status, accreditation, or contracts for services.  These are headaches that would impel just about any organization or individual to worry a great deal about operating according to plan and documenting the process, rather than ensuring a specific outcome. This of course is a very “functional” (or “instrumental“) form of process orientation.

A more “expressive” form of process orientation is also frequently seen in nonprofit organizations – manifesting as a desire to be flexible and responsive to changing situations, or as a desire to arrive at decisions through consensus.  However, it can be difficult to extend that attitude to technology, which tends to be difficult for non-specialists to comprehend, time-consuming, and expensive.

Another challenge is that organizations and individuals (including yours truly) can be reluctant to cut their losses, and say, “This isn’t working.  Let’s stop, figure out why, and decide on some next steps.”  Of course, in some settings, the decoded version of this message is “Let’s find someone to blame and punish…maybe YOU.”

Yikes!

Is there any solution in sight?  I only wish I had something certain and simple to offer.  Here are a few ideas, although none of them come with guarantees of success:

  • Techies need to understand the nonprofit organizational cultures in which they are operating.  Progress toward this goal is possible if the techies listen, ask questions, and listen some more.  These conversations should start early in the planning phase.
  • Nonprofit workers need to understand how technology innovations and implementations happen in real life, and have a reasonable idea of what factors can lead to unexpected outcomes in technology projects.  Progress is possible if – yes, you guessed it – the nonprofit workers listen, ask questions, and listen some more.
  • Everyone needs to cooperate in creating incentives for spotting, discussing, and correcting errors rather than evading their detection.  I freely admit that I always find it easier to do these things when the mistake was made by someone else, but am always striving to do better.

I wish I could remember who it was that first said to me, “This is not about one person against another. This is about our team against the problem.”  Anyone who can say that is a saint, a boddhisatva, a tzadik, or an unusually effective manager.

“We count our successes in lives”

Brent James

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.

My current daydream: The marriage of outcomes management apps with data visualization apps

The marriage of outcomes management with data visualization

Given my current preoccupation with both outcomes management and data visualization for mission-based organizations, perhaps it’s not a surprise that I’m daydreaming about integrating applications that were designed for these two tasks.

This daydream was inspired by a recent conversation with Patrice Keegan, executive director of Boston Cares (a HandsOn Network affiliate).  She is keenly interested in both outcomes and data visualization, and she leads a nonprofit of modest size that collaborates not only with many local partners but also with a national network of sister organizations that facilitate short-term volunteering.  In other words, Boston Cares provides a gateway to volunteerism for individuals, corporations, and community-based nonprofits, and then shares best practices with its counterparts across the United States.

What better poster girl could there be than Patrice, for my Cause, which is making it not only possible but easy for her to take her outcomes analyses and turn them in visuals that tell the story of the social impact of Boston Cares?

Moreover, what good is a cause and a poster child, without a poster?  Here’s mine:

Patrice Keegan of Boston Cares
Special note to software developers in the nonprofit sector:  please take a look at that bright, shining face, and give your efforts to the cause.

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