Goals and Guardrails

A colleague and I were discussing a project to try to coordinate the cooperation of several radiologists who currently work in silos. I asked him what main problem we were trying to solve. He said that the main issue was the lack of fairness: some radiologists read more studies than others.

I can understand where he’s coming from. It can be frustrating to be very busy – perhaps too busy – and feel like your teammates are not doing their share of the work. A sense of fairness or equity, is important. But is it really the goal?  

Choosing the right goal is vitally important. The problem is, there are many goal-mimics out there. Secondary goals, attractive false measures of success, and in this case, constraints can all seem like valid goals until you take a closer look.

A constraint is like a guardrail – it puts a limit on what you can do to solve your problem. Whether it’s a good thing or bad thing may depend on whether you are an optimist or a pessimist; it could be hampering your driving style or it might be keeping you safely on the road. Either way, going beyond it puts your project at some kind of risk. A guardrail is definitely not a goal. As my friend and colleague Greg Mogel wisely said, our goal in healthcare is not to increase the relative fairness in the world. Our goal is to take care of patients. While we do that, however, we need to try to create effective teams and satisfying careers, and fairness plays into that. But fairness itself a guardrail, not a goal.

One reason it may be so easy to confuse a constraint for a goal is that there are so many people whose job – or tendency – is to focus on a particular constraint. In healthcare you’ve got people who watch the budget, folks who monitor regulatory compliance, and others who measure and report on target metrics. At the same time you’ve got very smart, vocal workers who are quite aware of issues of fairness and equity and who are increasingly (and appropriately) worried about their own well being and burnout. You have plenty of people telling you that their favorite issue is the thing that should be optimized next.

And just because a constraint is not the mission of the project doesn’t mean that it’s not important. Steve Jobs’ “reality distortion field” notwithstanding, you can’t simply pretend that constraints don’t exist. If you want to see a dramatic example of what happens when people ignore constraints in favor of “solutions-oriented thinking” try watching one of the Fyre Festival documentaries.

I have seen too many meetings devolve into positional arguments, each person championing their particular goal or constraint as the main issue, in a “tastes great/less filling” type of back and forth. These conversations are structured as “or” questions: the most important thing is this or that, but certainly not both. While it is helpful to limit the number of goals, having a single goal doesn’t mean that nothing else matters. You have to determine your true goal, but you also need to accept and deal with the reality of the constraints. 

You might try having your team fill in this sentence:

We want to achieve X. But we also have to watch out for Y and Z.

X is your goal. You should be able to connect it very clearly to your essential mission. Y and Z are constraints. You can have more than two, of course, but it helps to focus on the most important ones.

Every point that someone raises is probably an ingredient of the problem and should be considered. You will have goals and constraints and all sorts of other factors in any sufficiently complex project. The trick is to correctly categorize all the parts, and the trap is to elevate the wrong one to the primary position. 

The biggest risk of choosing the wrong goal is that you might actually get there.

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