Outcome Observations

Outcome Observations offer written musing on a variety of outcome themes. They are different from the spoken thoughts on Result Radio and are updated twice monthly. 

#1 “Patient Activation” (March 2012) A cutting edge movement in medicine—and especially in Community Health Centers—focusses on what patients can do to manage and improve their own health. It starts with the assumption that the choice people make in such areas as exercise, diet, smoking, and alcohol are as consequential to health as is all of medical technology. This moves medicine to the change management field and to understanding how to help patients move from passively receiving services to actively managing their health. In many cases, the inability of people to create success for themselves is seen as associate with low self-confidence and self-efficacy. People have to know that they can change their behavior and that the change will lead to better health before they will take great initiative.

In many social and human service areas activating clients, consumers, or customers by another name would seem to fully apply. Do participants see themselves as receiving a service or as getting help to make intentional change? I am impressed with one promising step that takes the idea of setting targets from organizations and programs to participants.The national program called School Turnaround, a division of The Rensselaerville Institute (TRI) uses an intervention approach to reverse decline in failing schools. One of its tactics in the strategy around compelling outcome clarity is student target-setting.  Each student in the school knows what he or she is trying to achieve. I want to learn 5,000 new words…I want to learn how to spot the main idea and separate it from the theme of a book I read…I want to know how to make inferences—not just what is written but what it means. And—yes—I will move from a score of 63% to 78% on this test and here are the October and December benchmarks I will reach.     

When you go into a traditional classroom and ask students what they are doing you hear that they are reading a story. When you go into a School Turnaround classroom you hear that students are trying to learn how to spot the main idea on each page. What difference intentionality makes! How purposeful are your participants in your programs? Are they sitting through the session or are they looking to achieve something in each and every hour with you?  Perhaps “patient activation” can help.

#2 Riding for your brand (February 2012) Marc Chardon, the bright and inquisitive leader of Blackbaud Inc, and I have been doing some writing together. One theme we call, “Riding for the brand.”  Brands we note, do not establish a class or cohort of groups. They exist to define and protect the distinctiveness of an organization, whether a cattle ranch in Wyoming or a drug treatment organization in New York. Where’s our beef? It’s underneath our brand!

As foundations move from funding programs to investing in results, they shift from sprinkling money among many organizations to investing more on those organizations that achieve the strongest human gain for the dollars available.  Yet when I ask many nonprofits where they think they stand on achievement relative to other groups in their field and geography, most do not know. And a few shrink from the question—suggesting that this means having to at least implicitly call attention to differences with colleague groups. My advice is to get over that. You need a way to move from blending in to standing out

No need to badmouth other groups. You simply show your results relative to those of other organizations taken as a whole. You let the viewer draw his and her own conclusions. And if you are interactive with other groups to the point that shared action determines your success, say so. Be clear about how collaborations with other high achieving groups lets you together create results that are well beyond those that sum from your separable activities. Then supporting each party to the collaboration makes good sense to investors.

#3 Simplicity and energy from watching our words (February 2012) I was in Florida recently working with the Sarasota Community Foundation and its key constituencies, including nonprofits.   A common theme was the need to reduce complexity of outcome language and thought. I continue to find that the need to put so much material into the charts, graphs, and lists to appear “comprehensive” about outcomes denies the clarity and intensity needed to make a difference.  One of the participants in a session was Pam Truitt, senior staff member of the Patterson Foundation, an impressive group which collaborates with the Sarasota Community Foundation. Here is her blog entry on what she learned from my workshop.

#4 Leading by example (July 2011) Suzanne McLeod is Superintendent of Union-Endicott Central Schools in New York State. She participates in a program of School Turnaround called Get to Great. A key to this approach which helps good schools get great results is a set of prototype projects. While others may study and plan (ready…aim…aim some more…aim some more) Suzanne fired and then aimed—and in a way that prompted over 15 students who would have not passed courses this year to do so. This is actually enough to move a needle in the population of those most at risk for drop out. I urge you to click to read the short case on “No Tiger Left Behind.” This is a surprisingly low-tech approach that shows how that the human touch can make all the difference when concentrated on a specific group of kids at high risk. This project took half an hour of time per week of the superintendent’s time—less than the time spent watching just half of a sporting event or concert. And the difference for achievement in the school was profound.

#5 The high costs of togetherness (July 2011) I recently worked with 30 nonprofits in one region of a state in one-on-one consultations. Many called themselves networks, collaboratives, or partnerships that were presumed to yield the many gains of collective action. Instead I found they were as likely to express high costs and low speed forward. Specifically, I found three huge issues present in many of these convenings:

  • While the partners were all listed in close formation, I could get very few examples of how two groups had actually worked closely together to improve results for specific human beings. While the focus was often on changing policies or on advocating, few could relate that in any practical way to people getting to a medical home. The partnership was in name more than deed and when connections did exist it was far more about communication and coordination that in was about creating new solutions.

  • Much of the time in early years was spent on getting the structure and process right. Many groups held many meetings to understand the need, come to consensus, and agree on the by-laws or the logic model chart. All of this without any clear target for actual improved connection to healthcare. Most of these networks reported that it was very tough to keep up the energy and that attendance was flagging. Of course it was! Those with an itch to act to get 10 more uninsured patients to a medical home were out of there!

  • The images blur for foundations or others trying to figure out which groups of groups to support. How can so many collaboratives exist in the same space? In one case I noted that a nonprofit was a member of three networks in the same geography. When I asked which one was the most effective they said it was the one with the shortest meetings.

My conclusion was a stark one: if groups do not state a specific high bar target that is tangible and verifiable they will almost assured design to process and structure. While this can be sanctified by funder requirements or by the fashionable goal of comprehensiveness, or a consulting firm billing by the hour, the reality on the ground is that no one is helped very quickly. The issue compounds when we think of the several years taken by many groups of groups to prepare for action. In the groups I saw, an average of over 2,000 hours was spent by groups and many more by paid facilitators before anything was attempted to improve human lives and conditions.

I also have come to appreciate the image of the coalition, partnership, network or the same by any other name as a tent rather than a singular creature. In the tent, two of three groups find each other and launch small projects building on what works. They do not wait for consensus to act and show how early action informs design. People who find each other, forge new solutions, and achieve higher results show us that we can plan and act at the same time.

#6 The Extreme Edition Approach (May 2011) The of January 10, 2011 issue of Time Magazine has a story entitled, “Foster Care: Extreme Edition” about a St. Louis program that increased the number of kids who find foster care homes from 40% to 70% while reducing the time to do so from 1-5 years to well under half a year.  Like so many innovations it was not born in a long plan, a large committee or a pot of money. It started with a person.  As the magazine article notes, the stem-winder for this program, Melanie Scheetze was:

Sitting in front of the television in her family’s living room on a Sunday night in March, 2008 impatiently watching the last few minutes of Extreme Makeover: Home Edition. “How can they build a house that fast?” She remembers wondering.  “If they can do that—and they do it not because they use any new technologies or processes; they just coordinate their massive team of professionals and volunteers in a highly effective way—the question is why can’t we do that too in finding homes for kids?” 

Like most innovations, this one is breathtakingly simple in concept and does not require creating anything.  It is based on translating an approach from one domain (extreme makeover of houses in a few days) to another (finding foster care homes).  Invention is having a bright idea. Innovation is putting one to use.  
In this case, the core idea is concentrated and widespread action to do many things at one time.  How different this is from a social service approach that tackles problems in more isolated form and rarely if ever in the same space and at the same time. Also, note that this is not gentle change. It is intervention, designed to reverse or turn around an unacceptable situation in short order.  
 Or if that task seems too extreme, just name one thing you could do in half the time with no loss in quality. Bet you can! So…what are you waiting for?

#7 Putting Money and Results Together (May 2011) While working recently with some foundations I happened to look closely at how they looked at the financial and the program data in applications. I was reminded of just how far apart programs and money have become.  Foundations look at programs to see if they are feasibly aligned with mission, and clear on all details requested. They pick up a very different set of criteria to look at finances. At a project level are the costs reasonable by line item.  At the organization level is the organization sustainable.  

While separable analysis may work for funders it can never work for investors, where the gain is always relative to the cost. Indeed, the idea of return on investment starts with the investment level!  And it ends not with the cost per service delivered (the best you can do now with most proposals) but the cost per gain.  If a program serves 100 persons and costs $20,000 we could say that the cost is $200 per person.  But if only 10 of those 100 persons get a job, a year increase in academic achievement, a specified weight loss or anything else, the cost per unit of gain soars tenfold to $2,000.

Another relationship is between program health and financial health. If a group is low achieving, the worst case is that it attracts a lot of money and stays around to capture even more.  On the other hand, a high achieving group may not score high on the criteria of low overhead costs. It needs money to effectively track and verify its results, improve its products, and finance its growth. The worst scenario is a high performing group with the means to know just what is successful as the basis for growth. Minimizing costs is far different than optimizing them.

#8 What does compliance say about effectiveness? (May 2011) I was on a program in Columbus Ohio a few years ago with Bob Ottenhhoff, the director of Guidestar and heard him observe that in the next five years, information on effectiveness would trump information on efficiency. After a pause he added, “And Guidestar has no information on effectiveness.”  That is now changing but the reality remains: standard information on form 990’s (a tax filing by nonprofits) tells you about their income, their resource allocations, and their sustainability.  Other available information can tell you if the group is in compliance with regulatory agencies.  But what does this information on efficiency tell you about results achieved?  Precious little!

Many of us tend to rely on gold star ratings and endorsements and certifications of nonprofits to determine whether we will support them.  Yet when we dig in many of the factors that go into that gold star rating are surprisingly weak predictors of success for program participants.  I recently viewed a statewide set of standards for nonprofits that included such items as having board minutes filed in a timely way and policies present for a drug free workplace, etc.  I am certainly in favor of these but I see almost no correlation between them and achievement by or for those in need.  I am glad when preschools require master’s degrees and five years of experience but find these far less predictive of school readiness than enthusiasm and engagement ability.  How many of us remember a great teacher because he or she had a master’s degree?