The surgeon and essayist Atul Gawande gave a powerful commencement speech at Harvard Medical School last month. In his address, entitled "Cowboys and Pit Crews," Gawande explored how traditional approaches to practicing medicine must fundamentally change for the health care system to deliver the better care we need at a lower cost such that our society can afford it. He was speaking about the delivery of health care, but he could have just as well been speaking about the delivery of human services by nonprofit organizations.
Gawande’s premise is that the health care system has to shift from the practices of a traditional era "when doctors could hold all the key information patients needed in their heads and manage everything required themselves." Today, given the sheer unmasterable volume and complexity of our accumulated medical knowledge, and the range of specialized skills required to apply it, health care professionals need to work through well-tested and established protocols in highly aligned teams. But our health care system isn’t set up this way. "We train, hire, and pay doctors to be cowboys. But it’s pit crews people need."
It might be a little hard to think of the social workers, counselors, mentors, case managers, program directors, etc. that work in human service nonprofits as cowboys, but that in effect is how too many of them end up working—independently, trying their best, attempting heroic interventions on their own or via a single program, based on what their own experience and/or what they sense is the right thing to do for the people they are supporting.
The prevailing patterns of government funding for the delivery of human services are a primary driver of this cowboy ethic. These patterns typically assume that beneficiaries have one problem and one problem only; different problems have to be addressed through different funding streams, different programs, and different practitioners. Beneficiaries can be hungry, homeless, mentally ill, high school drop outs, emancipating foster youth, or drug addicts, but if they happen to fit more than one or two of these descriptions at the same time, as so many do, publicly funded systems of support in nonprofits are frequently hard-pressed to respond in a coherent and integrated fashion.
Moreover, the sense of mission and commitment that most people working in human service nonprofits bring to their endeavors can often reinforce and exacerbate these patterns, further normalizing the cowboy ethic. The considerable compassion, creativity and drive of these professionals often goes into bucking the existing and faltering systems on behalf of the individuals and families they are supporting. Battles are won but wars are lost as beneficiaries fall between the cracks of missed or botched handoffs between programs they need, powerful results from demonstrated best practices at one site are not systematically driven across all other sites doing the same work, and the root causes of success or failure in realizing outcomes are left unobserved in the fray of the day-to-day.
It doesn’t have to be this way. We have seen profound breakthroughs when nonprofits seek to harness and coordinate the efforts of their people and program teams so that they are working together, more like well-oiled and carefully rehearsed pit crews, to support their beneficiaries. Consistent with what we have observed in such high-performing organizations, Gawande lays out three basic shifts that—taken collectively—can lead to breakthrough results:
Measuring performance to support ongoing improvement: "You must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance."
Using checklists to manage complex, interdependent processes: "You must grow an ability to devise solutions for the system problems that data and experience uncover….[checklists are] the basic tools of the quality and productivity revolution in aviation, engineering, construction—in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution."
Establishing the values and culture of teamwork: "The ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy."
This set of three items is itself a good overall checklist for you to start with—how does your organization stack up against it? What else have you found to be helpful in shifting from a cowboy to a pit crew ethic?
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