[Passing another kidney stone, so I’m doped up with pain medicine. I apologize for all the free association, but it’s for a point. At least, I think so.]
In the last post, I raised the (to me) difficult question of how to manage programs, such as missions programs, where some efforts seem very successful and others are struggling. It’s an issue church struggle with everyday: a young man volunteers to go overseas at great risk and personal sacrifice and it’s not going so well. Do you pull him out and bring him home? Keep on waiting for things to turn around? Or what?
Now, every case is going to be different, but I think some overarching principles would be helpful to the discussion. So I thought I’d try to think about it like, well, a class in game theory. Now, that’s obvious, isn’t it? (Where else do you get lessons on the application of game theory to church leadership issues??)
But game theory is too complicated for a church blog. In fact, it’s pretty boring. So I’ll hide the game theory in some other clothing. A parable: imagine that you’re attending a seminar on how to run a nonprofit medical care program, built on Christian values.
Class, today we’re going to talk about a management question. Suppose you’re the CEO of a nonprofit parachurch organization that’s chartered to provide medical care to the poor. There’s a shortage OB/GYN doctors in your community, and the doctors you have refuse to take Medicaid patients because they can make more money working exclusively with private insurers, who pay more.
You’ve gotten a grant that will pay for 5 nurse practitioners who are trained as midwives, who’ve agreed to work for you to handle indigent care for pregnant women. Each one can handle 1,000 cases a year. If they take any more, the quality of care will drop, babies will die, and you’ll be unable to maintain your malpractice insurance and you’ll lose your grant. 1,000 per year is an absolute limit.
You’re responsible for a 5 county area. No one else is going to care for these women if your nurses don’t.
Tuscaloosa County has 250,000 people and could use as many as 20 nurse practitioners. The surrounding counties, Bibb, Greene, Fayette, and Pickens, have only 40,000 people among them, but they are disproportionately poor. Each of these four counties generates 850 cases per year.
The patients will generally be unable to travel out of county. Most rely on public transportation that doesn’t cross county lines. Many of the rest work fulltime jobs that won’t give them enough time off to travel an hour and back for a medical visit.
Where do you put each nurse? The teacher gestures to a map showing the 5-county area, with Tuscaloosa in the center, surrounded by the other, poorer counties. Each has a county seat in the middle of the county.
The class doesn’t answer at first. Soon, a young women in the front says, rather condescendingly, “Of course, you put one nurse in each county. If you don’t, you’ll leave thousands of women without medical care! I mean, I just couldn’t look myself in the mirror … ” Her voice trails off, as she imagines the guilt of providing health care in only one county when she could care for 5.
Another woman responds, “But the nurses in the outlying counties can’t serve a full 1,000 patients! If you do it her way, you’ll leave 600 women uncared for who you could have treated!”
“But,” the first woman complains, “you just can’t leave a county entirely uncovered. I mean, that would leave 4 entire counties with no heath care at all! That would be heartless! We are an organization built on compassion, not statistics. We’re not a business!”
The teacher begins drawing on the blackboard. On one side he sketches 5 gold bars. On the other side he sketches another 5 gold bars, except 4 are smaller bars. “If a rich man gave you a choice to give one stack or the other to the poor, which stack would you give them?”
Everyone agreed that they’d give away the stack with the most money.
“Well,” he asked, “what if you had to give the 5 whole bars entirely to Tuscaloosa County poor or you could divide the smaller stack any way you want within the 5 county area? … and everyone is equally poor?
The class struggled more with this one. “Tuscaloosa is a much wealthier county than the others,” a third student offers. “It wouldn’t be fair for that county to get all the money!”
The second student rejoined, “But you aren’t giving the money to a county. We’re here to help people. What makes a Fayette County person worth more than a Tuscaloosa County person? How can we pick based on location?”
The teacher rejoins the discussion. “You know,” he begins, “the idea of a group identity defined by political lines is very Western and very recent in human history. I mean, some political body drew these lines 200 years ago, and we can hardly decide people’s fates based on county lines if we can help it! That’s what politicians do. As soon as we worry about X county versus Y county, we’re thinking like politicians, not Christians.
“I mean, its about people and just people. The fact that Tuscaloosa County, as a whole, is richer than Greene Country, hardly means that their poorest residents are richer than the poorest in Greene County. Poor is poor!
“Let me rephrase the original question, in harsher, but truer terms. How many babies are you going to kill?”
The class was horrified. “We’re not going to kill babies! We’re just allocating nurses to locations!”
The teacher smiled, “And if you make bad decisions, more babies and women will die than if you make good decisions. What’s the answer if think in terms of maximizing baby lives?”
Everyone responded, “Give all the money to Tuscaloosa County.”
“NO! NO! NO!” the teacher shouted. “Tuscaloosa County is a government. Governments don’t have babies. Give the money to 5,000 pregnant women rather than 4,400 pregnant women. It’s just that simple!”
“Actually, professor, it’s not.” A student in the back spoke up for the first time. “What if we put the nurses closer to the county lines and allow more women from out of county to reach their nurse. And maybe we triage the women, so the ones with the most severe needs or who can best be helped get treatment. Rather than placing them in the county seat, why not move some of them toward the borders so the women who can get to them from out of county?
“Or,” and student suggests, “why not put them all in one place, save overhead, and reallocate the savings to provide better transportation?”
“Or have a nurse rotate among the counties. Let’s put three in Tuscaloosa and have the other two cover two counties each!” a fifth student exclaims.
The class continues batting ideas around, and the teacher leans against his blackboard smiling. At the end of the hour, he says, “Class, I’ll spare you the “thinking outside the box” cliches and try to get to the point.
“You found several solutions to the problem by, first, clearly defining success. When I defined success as babies lives saved, you saw that the issue was important enough that merely symbolic but wasteful gestures would no longer do. Sacrificing 600 babies a year just to feel better about yourself because you covered every country would be a bad trade!
“But once you saw the problem properly defined, you felt compelled to truly maximize resources by saving overhead and such so every dollar was spent the best way possible.
“Now, you’ll never know the exact answer until you have a real problem to deal with — but the key is to get away from quick and easy answers that feel good and leave babies for dead. Always think in terms of the mission. In this exercise, the mission was saving the lives of babies, not covering geographic areas or political subdivisions. Getting the mission right will usually get you most of the way to the best solution.”
