SMART vs Unrealistic

Is it okay to tell people you’re going to do something that can’t be done?

Is it okay to set an impossible goal and then quickly back away from it?

Two healthcare ethicists recently argued that the answer to those questions is “yes,” in an American Journal of Public Health article titled “On Knowingly Setting Unrealistic Goals in Public Health.

Though focused on public health initiatives, the article caught our attention this Spring because of the ongoing conversation here at Jarrard Inc. about the purpose of mergers and acquisitions. With transactions becoming an even more significant strategic imperative as providers look to scale – or survive – in the wake of COVID-19’s financial disruption, the messaging around M&A has become commensurately more important.

Back in early January, a study published in the New England Journal of Medicine showed that mergers don’t improve quality or patient experience. As we wrote then, “The problem here is that hospitals have long touted these metrics as reasons for a merger. It’s more about the unfulfilled expectations – set by hospitals themselves – that made it a story.” Hospitals said quality would improve, so it was disappointing (or worse) when it didn’t in the way or on the timeline they had planned.

And so it was intriguing to see two ethicists arguing for setting unrealistic expectations. We were skeptical.

The authors highlight several public health initiatives over the past 20+ years, including one focused on dramatically increasing the number of people on anti-retroviral therapy (ART) for HIV/AIDs within two years and others seeking to get a variety of negative outcomes to zero – deaths from childhood TB, kidney failure, malaria, etc.

In all cases, the goals were unrealistic, and likely knowingly so. On the surface, it seems disingenuous at best for initiative leaders to prophecy a world without malaria, or a world where three million people in low-income countries have access to ART. Especially if, two years later, you’re one of the people who still doesn’t have that access because, well, it was never really going to be three million. But maybe it’s not so bad…?

Because on closer examination, the authors are not advocating for magical thinking. Setting a goal of a world without malaria is very different than saying, “next week we’ll wake up in a world without malaria.” Or, to put it in the terms of Summer 2020, there’s a difference between setting a goal of no new COVID-19 cases and saying it will burn itself out on its own.

Anyway, the authors point out that unrealistic goals can be useful by “bolstering motivation, attracting resources and coordinating efforts.” In the case of the HIV/AIDS initiative, the number of patients on ART tripled, even though it did not hit its stated target. Would that have happened without the (unachievable) target?

“Zero harm” initiatives are another subject of the article. If an organization has a goal of zero preventable deaths, “in a sense, anything exceeding zero is wrong here. By definition, any error should be avoided.” But of course, errors are a reality, no matter how extensive prevention programs are. So, the authors suggest, the idea behind “zero harm” is good but shouldn’t be overstated.

It’s a fine line. Zero preventable deaths is impossible yet good. Pushing towards zero can motivate people to take actions to improve and to find creative ways to change for the better. Would they do so in the absence of a zero-harm initiative?

This point brought to mind a comment from a health system CEO last year. He said that early in his tenure, the organization was trying to reduce hospital-acquired infections (HAI). They were using percentiles to figure out how they stacked up against other providers. The CEO asked why the focus was on moving down the curve – creating less harm than most other facilities. Instead, he said, the goal should be no harm. The result was a shift in thinking across the organization, which led to action. With a goal of zero, people actively pursued new ways to avoid HAIs.

This scenario perfectly highlights the clarity and motivation created by an “impossible” goal. The point is to have something to work towards. It’s not dishonest or distracting. Just the opposite – it’s clarifying.

Once the unrealistic outcome is set, though, progress is needed – otherwise it does become dishonest. And making progress requires developing “realistic targets” soon after the big splashy announcement (or even before). The authors frame it this way:

“First, set the unrealistic […] goal as though you meant it literally […] Second, ensure that the merely figurative nature of the goal becomes manifest shortly thereafter by keeping the specifics realistic.”

Once you read past the academic-speak that, frankly, makes it sound like they’re still soft-peddling a bait-and-switch, the point is that a leader can essentially say, “here’s what we’re aiming for, and here’s how we’re going to move in that direction.” Providing specifics allows people to channel their motivation into real action. This is where the SMART framework comes into play. Create milestones that are specific, measurable, attainable, and time-bound. Those will drive progress towards the unrealistic goal, and (news flash!) progress is better than a lack of progress.

Finally, a note on language. As we read the article, we wondered whether calling an unrealistic goal a “goal” was the right terminology. Perhaps it should be called something else like an ideal state? As in, an ideal world without malaria. Fortunately, the authors also address this, too. Highlighting an effort by the World Health Organization to eliminate TB, they say,

“[It] differentiates between a ‘vision’ of ‘zero deaths […],’ a ‘goal’ to end the global TB epidemic, and ‘targets’ of a 90 percent reduction in TB incidence rate.”

This may be the most helpful piece of the article, and the most important lesson for anyone setting goals and making promises. Specifically, use clear language and define the language you use. A vision is not a strategy, a goal is not a vision. Clarity here, perhaps more than in any other area, can help avoid accusations of dishonesty and criticism when utopia doesn’t appear.

Clarity of language allows a leader to say, “Look at the incredible progress we’ve made and we’re going to keep working on doing more.” The alternative is, “Well, we didn’t really mean that. We were just trying to get people to pay attention.”

Now, the issue of post-merger quality becomes much clearer. It’s not that executives set a goal of improving quality or reducing cost after a merger, it’s that they promised those things would happen. A critical if subtle distinction. And an entirely avoidable one.

David Shifrin