By Eric Gombrich
As a sailboat racer I’ve long appreciated the importance of knowing my singular destination. The difference between winning and losing after days of racing can often times be determined by mere seconds. During the journey, any ambiguity in the specific destination sought can be the difference between victory and defeat. Any distraction of a tactic supplanting the 1 true goal can be devastating.
In navigation activities like sailing or flying a plane, this is often-times referred to as ‘True North.’ But even then, there can be ambiguity.
According to Wikipedia:
True geodetic north differs from magnetic north (the direction a compass points toward the magnetic north pole), and from grid north (the direction northwards along the grid lines of a map projection). Geodetic true north also differs very slightly from astronomical true north (typically by a few arcseconds) because the local gravity may not point at the exact rotational axis of the earth.
The direction of astronomical true north is marked in the skies by the north celestial pole. This is within about 1 degree of the position of Polaris, so that the star appears to trace a tiny circle in the sky each day. Due to the axial precession of the Earth, true north rotates in an arc with respect to the stars that takes approximately 25,000 years to complete. Around the year 2100 to 2102, Polaris will make its closest approach to the celestial north pole (extrapolated from recent Earth precession). Five thousand years ago, the closest visible star to the celestial north pole was Thuban.
On maps published by the United States Geological Survey and the United States Armed Forces, true north is marked with a line terminating in a five-pointed star. The east and west edges of the USGS topographic quadrangle maps of the United States are meridians of longitude, thus indicating true north (so they are not exactly parallel). Maps issued by the United KingdomOrdnance Survey contain a diagram showing the difference between true north, grid north, and magnetic north at a point on the sheet; the edges of the map are likely to follow grid directions rather than true, and the map will thus be truly rectangular/square.
This concept isn’t limited to competitive sailing. It applies in many competitive pursuits, both explicitly and implicitly, from road rally racing to the Tour de France, and even in more mainstream sports like baseball, hockey, and football. Where to position players, where to shoot, what to defend, when to accelerate and when to decelerate; these are all concepts that are entirely dependent on absolute clarity in where the destination – the goal – is located. Just imagine what a basketball game might look like if the players didn’t know or had different beliefs in where the basket was located. Organized chaos!
It also applies to business and even to healthcare. And I contend that lack of clarity on ‘True North’ in business and in healthcare is often at the root of failure or sub-optimal performance.
I believe this point can be exemplified in David J. Bailey’s June 2017 contribution to the Harvard Business Review entitled “Value Based Care Alone Won’t Reduce Health Spending and Improve Patient Outcomes”.
In this article, Mr. Bailey summarizes the 2012 project undertaken by Nemour’s Childrens Health in an attempt to apply Value Based Care (VBC) to children with Asthma in order to improve outcomes. As great as the article is (only to be surpassed by Nemour’s work itself), and while not the focus of Mr. Bailey’s analysis, I think Mr. Bailey under-appreciates one of the key elements of the project and the team’s management thereof; defining True North.
From the article Mr. Bailey states:
In 2012 Nemours implemented a pilot program to improve asthma outcomes — asthma is the most common chronic disease in childhood — for a population of children in Delaware, where we had an established network of primary care clinics and where, in 2004, we established Nemours Health and Prevention Services, a freestanding population health division dedicated to addressing the social determinants of health in collaboration with the larger community.
He then later goes on to state in the article:
Passage of the Affordable Care Act, in 2010, signaled the advent of VBC and an emphasis on population care. Since most of Nemours’s patient revenue was from fee-for-service contracts, we designed this pilot program to integrate our population health expertise with our clinical operation, in an effort to better understand value-based care and reimbursement models and to further improve health outcomes in a population of children with asthma.
Can you see the ambiguity? The multiple ‘goals’ – or ‘True Norths’ – that are identified?
In the first statement, it is indicated that the objective is “to improve asthma outcomes.” In the second paragraph he states “…in an effort to better understand value-based care and reimbursement models and to further improve health outcomes in a population of children with asthma.”
Which is it? Did Nemours intend to “improve outcomes,” or to “better understand [VBC] and reimbursement models…?”
“Can’t they do both?” you might be wondering. I contend “not effectively.” Here’s why…
If the ‘True North’ – the primary and prioritized goal or objective – is to improve outcomes for these kids, you can anticipate them doing things to achieve that specific goal. This might include things like reorganizing the care team around the patient; increasing the frequency of visits and/or communication with the patient (or their parent); developing or implementing an app to monitor the patient’s use of medications; etc. Many or all of these examples run the strong likelihood of increasing costs.
So let’s go back to the intention: “improve asthma outcomes.” Did we mean clinical outcomes for the patient? Did we mean financial outcomes for the patient? Did we mean quality of life outcomes for the patient? Did we mean lower the cost of care for Nemours? Quality of life for the Nemours providers? What does “improve outcomes” really mean?
Further, if we consider the second statement “in an effort to better understand value-based care and reimbursement models and to further improve health outcomes in a population of children with asthma” it gets even more confusing.
The unintended consequences associated with the lack of clarity can be profound. If we define improve health outcomes in a population 1 child ‘doing better’ would achieve that goal. We can claim success simply because the phrasing was not ‘improve health outcomes for the entire population.’ But perhaps even more troublesome is that this second statement suggests the pilot was really to learn about VBC and reimbursement models, and outcomes (however defined) are actually secondary (read: less important) goals.
One might infer from the article that the learning was the primary goal. And clearly, there were some great learnings achieved. But it caused me reflect on how we routinely see this type of ambiguity in the definition of our goals in business and in healthcare. This can result in tremendous churn, inefficiency, cost, and risk.
To resolve this, it requires concerted effort on the parts of leaders to work thru and define the truly and singularly #1 priority. It may seem easy, but try it. Here are a few tests:
- If the statement of the goal includes the word ‘and’ is it clear which of the conjoined concepts is the priority? It will supersede the other in terms of importance; the latter can be neglected in pursuit of the priority?
- Can it be quantified in some way? If not, it’s likely ambiguous.
- Doing the #1 priority cannot be sublimated by anyone; including the board or the CEO. This can be particularly difficult in healthcare, as every organization I know speaks to quality of care, outcomes, etc. yet looming in the background is the fiscal reality that doing what’s right for the patient might bankrupt the organization.
This is hard stuff. Far too many organizations I’ve worked with wrestle with this routinely but do it passively, because it’s so hard. It can be fascinating and revealing to pull together stakeholders from throughout the enterprise and even attempt to work thru the labyrinth of issues that can arise from lack of clarity on ‘True North.” This in turn results in different team members defending and shooting at different baskets.
How about your organization? Is your ‘True North’ clearly defined, and understood by everyone on the team? Or are you suffering from ambiguity in what the real destination is?
May your seas be calm, and fair winds at your back; happy sailing.