The Spread of Innovation: Scaling

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Atul Gawande

Atul Gawande has an article in the most recent The New Yorker about why some innovations spread quickly and how to accelerate others that don’t gain traction.  Gawande is a surgeon and faculty member with the Harvard Medical School who has written extensively about different strategies for improving professional performance.  He focuses primarily on health care, and I’ve blogged about some of his articles because they offer general lessons that extend beyond medical practice.

Gawande points out the following pattern of many important but stalled innovations: “They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful.”  He is working on a major project to spread safer childbirth practices throughout the world—“[s]imple, lifesaving solutions have been known for decades.  They just haven’t spread.”  Hand-washing by birth attendants before vaginal examination and delivery, for example, and swaddling newborns against their mother’s skin to prevent common and deadly hypothermia.  The problem is not a lack of adequate technology.  “Getting hospitals and birth attendants to carry out even a few of the tasks required for safer childbirth would save hundreds of thousands of lives.”

Rather than focus on instructional videos, or some combination of penalties and incentives, Gawande’s project creates a cadre of mentors to work directly with birth attendants and hospital leaders in changing their practices.  The idea is that “[t]o create new norms, you have to understand people’s existing norms and barriers to change.  You have to understand what’s getting in their way.”  The other idea behind the mentor approach is “that people follow the lead of other people they know and trust when they decide whether to take [a new idea] up.  Every change requires effort, and the decision to make that effort is a social process.”

This article made me think about the School’s work, and not because I’m suggesting that we move into international health care.  Relax.  It highlights a couple of organizational issues for us that are important to reflect on.

The approach of using mentors to bring about improvements is exactly what our faculty members have been doing since the days of Albert Coates to help improve state and local government.  Working directly with public officials over time means that they know us and trust us.  North Carolina officials understand that we don’t bring a policy agenda to our work.  Their experience over time is that we partner in helping them accomplish their goals, and they know it is our only motivation in offering legal or any other advice.  As Gawande says, “human interaction is the key force in overcoming resistance and speeding change.”  The School’s faculty members partner with officials to understand their challenges—from their perspective—and work closely with them in bringing about improvements in government.  We must always remember that those relationships are important to the success of our mission.

Gawande says the most common objection to his project is that one-on-one, on-site mentoring is not scalable.  He points out that it surely is scalable, though it could “require broad mobilization, substantial expense, and perhaps even the development of a new profession.”  Gawande notes that the creation of anesthesiology meant doubling the number of doctors in every operation, and that reducing illiteracy meant building schools and training professional teachers.  His project is scalable, but the challenge may be in persuading people that the benefits outweigh the costs.

I’ve been thinking a lot about scalability in terms of School programs.  For a number of our training programs, the demand is much greater than our current ability to deliver them.  Willow Jacobson’s new program for emerging leaders is only one example.  It is a labor-intensive program that requires many one-to-one interactions with the students—while they are in Chapel Hill for the program and for coaching and other follow-up once they return home.  The feedback from the students has been very positive, and our early evaluation efforts indicate that real change in their behavior is taking place.  There is a long waiting list for the course at a time when local governments are eager to develop the next generation of leaders for our cities and counties.

For Willow’s course and selected others, and for our advising, can we scale what we do?  Gawande’s mentors are offering fairly simple advice and the challenge is in getting people to accept it.  Our teaching and advising tend to involve much greater nuance and complexity, though North Carolina officials generally are willing to accept it.

How do we expand our capacity without reducing the quality?  Can we involve others who could expand our capacity under appropriate supervision?  How do we retain the credibility and trust that comes from working directly with our faculty over time?  Could we expand our work outside of North Carolina, partly as a way to provide more funding for our current work as state funding declines?  What would the business model look like?  Our faculty and staff are committed to our mission and they are working hard.  Whatever the answer to the scaling question, it is not about working harder.

I’d like to see us explore more intentionally the question of scaling our work.  I’m not sure that we have either the time or expertise to answer the relevant issues by ourselves.  Why not hire an outside consultant who might help us think about whether and how to do it?  There are lots of organizations that face this same issue, and I suspect that we have a lot to learn from them.  I’d be interested in your thoughts about whether and how we might explore scaling.

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