Scores on the midwife’s doors

Those of you who have either given birth or witnessed a birth will probably have missed it at the time. That’s understandable. A bundle of magic has just entered your life and you’re probably weeping, smiling and just glad its over, safely.

After the magical moment of delivery a very simple thing happens that doesn’t involve hi-tech equipment or expensive medication. All that is required is a biro a form, and the observational experience of a midwife.

One minute after birth, your baby will have been given a score. A number out a ten. This scoring exercise is then repeated 4 minutes later.  This simple number has saved countless lives since its invention. Annually there are 130,000,000 births worldwide so the stakes are reasonably high. The scope for impact is huge.

This small but powerful number is know as an Apgar score.

A brief history of a score out of ten

Virginia Apgar, was not a obstetrician. In fact, she was an anaesthesiologist. But she cared about data and clinical outcomes. And births interested her and so she came up with the idea for a score of a newborn’s vital statistics at birth. She published her thinking behind the methodology in 1955 -and it caught on.

“The score turned an intangible and impressionistic clinical concept – the condition of new babies – into numbers that people could collect and compare. Using it required more careful observation and documentation of the true conditions of every baby – Atul Gawande”

The reasons why the Apgar score caught on are because it’s practical, easy to calculate and provides immediate feedback. It works as a force for improving individual births but it has had a system level impact too. The score led to changes in how childbirth is managed. Scores began to be collected and analysed. This drove improvements in delivery practices. The results are stark. Consider the USA numbers: In 1933, 160,000 babies and 27,000 mothers died in childbirth, while now 1/500 full term babies die in childbirth, and less than 1/1000 mothers – and that’s from 4,000,000 births annually. The Apgar score has dramatically improved outcomes.


Minimal viable innovations

The Apgar score is what we would call a minimal viable innovation. An innovation that doesn’t attempt to fix or re-engineer a complex system by ‘boiling the ocean’, but addresses or supports a specific practice, simply and effectively. A minimally viable innovation doesn’t ignore context or systems: it is designed with systems in mind but doesn’t try to fix the entire system.

The Apgar score attempts to do one thing – provide a quick and clear measurement of the health of a baby across five key dimensions – at the most important time in its life – so that problems can be quickly identified and acted upon. It also contributes to improvement at a system level.

We’ve borrowed this example from Better: A Surgeon’s Notes on Performance– a book by medic and writer, Atul Gawande. Gawande is interested in complex problems and simple solutions. Working in the American healthcare system he is very familiar with complex problems. He’s also tired of complex solutions to these problems.

Beyond his day job he has devoted his career to exploring how simple solutions can play a part in solving complex problems. For example, he has written at length about the humble checklist . Checklists are used healthcare, and in other dangerous, complex, hi-tech or stressful environments like airline cockpits. They are also deployed on projects with large numbers of moving parts and parties – such as construction sites for large buildings.

These innovations that interest Gawande can be characterised as ones that demonstrate extreme simplicity in contexts of vast complexity. Their power lies in their understanding of the contexts in which people operate and how they tend to behave in practice. They are innovations that work with (not against) the grain of people’s behaviours and the contexts in which they operate.

Complex innovations for complex systems

Innovations designed to tackle complex problems often fail to exhibit the simple formula of the Apgar score and other minimal viable innovations. They correctly diagnose the complexity of the systems they are addressing and then seek to take on the entire system – or ignore the inconvenient truth of system complexity.

We see this scenario of ocean boiling play out healthcare regularly. Technology to help people monitor chronic condition (like diabetes or COPD) have been much hyped. But their impact has, to date, been relatively small given the obvious promise. On paper – and even as prototypes or products – they look like no-brainers. In reality they can be overly complex ‘solutions’ struggling to work in complex systems. The result is lack of impact.

So if that’s the diagnosis. What’s the prescription?

Think minimal viable innovation

1. Think big, but not too big.
Don’t reign in your ambition to make a dent on the universe but do weigh that ambition against the constraints imposed by system complexity and available resources.

2. Understand the system, identify your entry point
Understanding the system and its dynamics before identifying the specific angle of focus – the specific problem, behaviour or practice that you want your innovation to address.

3. Identify the forces, friend and foe
Its important for a minimally viable innovation to work with the grain of a system. Understanding the forces that will support or hinder your intervention. What behavioural patterns or economic incentives can you piggy back on? What factors, such as environmental or technological complexity – will work against your efforts?

4. Start simply and assess
What’s the simplest response to the opportunity which will allow you to understand and measure impact? What’s the measure of impact you’re going to use? If you have’t decided that outcome measure at the outset it’s likely that your intervention is not sufficiently focused.

In a recent post Stewart Butterfield  (founder of Flickr) spoke of innovation as follows:

The best — maybe the only? — real, direct measure of “innovation” is change in human behaviour. In fact, it is useful to take this way of thinking as definitional: innovation is the sum of change across the whole system, not a thing which causes a change in how people behave.

We think it’s both changes to how people behave and to the system – and a minimal viable innovation is one route to getting change at the individual and system level. And that is what creates impact.