Of Hedgehogs and Flywheels

With the publication of the tenth volume of the Anthology series, the Robert Wood Johnson Foundation has reached a milestone. In his foreword to the first volume, my predecessor Steven Schroeder wrote, "The chapters selected for this volume offer only a glimpse of the richness and diversity of our interests. A more complete picture will emerge with the publication of future volumes of the anthology over the coming years."1 A decade later, the Anthology has published more than 100 chapters that do, indeed, offer a more complete picture of the ways in which the Foundation has worked to fulfill its mission of improving health and health care for all Americans.

Because the appearance of a tenth anniversary volume is significant, I felt it would be appropriate for me to provide a context for the book by examining how the Robert Wood Johnson Foundation, in carrying out its mission, strives to be not simply a good philanthropy but a great one. I do not use the word "great" lightly nor do I wish to be immodest in stating our aspiration so boldly. But all of us—board and staff alike—take our work seriously and are committed to making the Robert Wood Johnson Foundation as great as it can be.

In this regard, we have benefited from the work of former Stanford Business School professor Jim Collins, whose two books, Built to Last2 and Good to Great,3 analyzed the factors that distinguished great companies from merely good ones. Collins extended his analysis to the nonprofit world in a recent monograph, Good to Great and the Social Sectors.4 His thesis can be summarized succinctly: Greatness is largely a matter of conscious choice and discipline—disciplined people, disciplined thought, and disciplined action.

Applying this to the Robert Wood Johnson Foundation leads us to take away four lessons.

First, defining greatness for a philanthropy is less clear cut than in business, but it is essential to agree on a definition.

While the Foundation uses "impact" as a shorthand term, Collins would say that greatness for nonprofits must encompass superior performance and lasting endurance, as well as a distinctive impact. In other words, the Robert Wood Johnson Foundation can claim to have had an impact when it causes or facilitates enduring change in an area that improves health care delivery or people's health and thus their quality of life.

Inevitably, we fall into the trap of enumerating specific programs or actions that have caused enduring improvements in health or health care. Yet research suggests that it is not single blockbuster programs that produce impact but rather the combination of disciplined people's thoughts and actions that create greatness over a sustained period of time. The key is to rigorously and routinely assemble the evidence—be it quantitative or qualitative—that allows one to assess performance, discipline, and momentum.

 

Second, in order to be great, we must apply the Hedgehog Concept.

The Hedgehog Concept derives from an ancient Greek poem attributed to Archilochus of Paros which loosely translated says, "The fox knows many things, but the hedgehog just one big thing." In other words, the fox is scattered, diffuse, distracted. In contrast, the hedgehog simplifies the complexities of the world into a single unifying principle that guides all of its activity. Focused, determined, relentless.

Great organizations are disciplined in thought and action as they define the intersection of these circles and stay focused on it. This has been our biggest challenge. The temptation in philanthropy is to take on many things because they will do some good. In looking at the three circles comprising the Hedgehog Concept, we know that we are passionate about helping Americans live healthier lives. We know, too, that we do well training leaders in health care, incubating innovative models to deliver needed services to vulnerable populations, creating the evidence and advocacy that can drive policy change, and identifying the important areas that have the potential to transform the health of the people we serve. Our resource engine is not the generation of revenue but rather the combined power of our financial assets and the intellect of our staff and grantees, from which our good reputation derives. Mastering the Hedgehog Concept is more difficult than depicting it, but I think we are making progress.

The Foundation's Impact Framework helps us stay focused on those things we do best. It groups our work into four different portfolios, sets goals, and assigns resources to each portfolio.

  • By putting all the training and fellowship programs together in the Human Capital Portfolio and charging a group of staff members to think about workforce needs in health care, we stay focused on creating health care leaders—whether they be community health leaders, policy research leaders, or national leaders.
  • The Vulnerable Populations Portfolio focuses on incubating innovative models to deliver care to the elderly, new immigrants, teenage mothers and their children, the chronically homeless, and others who are often marginalized or forgotten.
  • The Targeted Portfolio takes a few areas such as quality, childhood obesity, public health infrastructure, and health care disparities, among others, and applies our ability to build an evidence base and to use it to advocate for the changes that will help Americans live healthier lives.
  • Finally, the Pioneer Portfolio drives us toward continually incubating innovation.

 

 

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Yet, even with a structured Impact Framework, we find it difficult to be disciplined and to say no to ideas and programs that are clearly worthwhile but do not fit within our portfolios and strategies.

A few words about the engine. More and more, we must fine-tune the firing of all of its cylinders—our financial assets, the dedication and expertise of the staff, and the Foundation's reputation. For many years, the Foundation made an effort to speak through our grantees. As I discussed in the foreword to last year's Anthology, we now talk about connecting, communicating, coordinating, and convening as deliberate strategic investments of staff and financial resources to speak with and on behalf of our grantees.5 Collins emphasizes the importance of nonprofit organizations having a strong identity, and tuning the engine this way reciprocally enhances the reputation of our grantees and the Foundation.

Third, the Flywheel Concept describes the payoff.

Creating transformative impact—improving the health and health care of all Americans—suggests turning a giant flywheel. Remember the concept from Physics 101—a heavy wheel that is hard to turn until it gains momentum and then is almost unstoppable. The image of the flywheel I like best is that of the child-propelled merry-go-round. They were ubiquitous in the playgrounds of old. Do you remember the flywheels designed for us kids to grasp as we ran faster and faster until the merry-go-round's momentum swept us off our feet? Then we would jump on to the spinning disk, screaming as we reaped the joy of our collective effort. In Collins' words, "By focusing on your Hedgehog Concept, you build results. Those results, in turn, attract resources and commitment, which you use to build a strong organization. That strong organization then delivers even better results, which attracts greater resources and commitment, which builds a stronger organization, which enables even better results." People want to feel the excitement of being involved in something that just flat out works. When they begin to see tangible results—when they can feel the flywheel beginning to build speed—that's when more people line up to throw their shoulders against the wheel and push.

 

 

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The Foundation's flywheel is gaining momentum. Consider, for example:

  • Significant changes in tobacco use and policy in the United States. The Foundation has supported organizations working to affect the price of cigarettes, understand the impact of secondhand smoke, and establish clean indoor air policies. In December 2005, USA Today reported that 39 percent of Americans are covered by smoke-free laws or regulations (surpassing the Foundation's target of 35 percent by July 2006).
  • Care of HIV/AIDS patients. In the 1980s, Foundation-funded hospital surveys documented the cost of care for HIV-positive patients. This led to Congressional testimony, then to funding of outpatient care for AIDS patients, and ultimately to funding for care of those with HIV-related illnesses. Foundation-funded demonstration programs provided the model for the Ryan White Act, the federal government's primary source of funds for care of people with AIDS.6 At a 2004 Time/ABC News Summit on Obesity, Peter Jennings, the late ABC News anchor, publicly thanked the Foundation for the momentum it had generated in HIV/AIDS care.
  • Children's access to health care in schools. The Foundation's funding of school-based health programs began in the 1980s and continued through 2005. These Foundation-funded programs helped expand the number of school-based clinics, which now number about 1,500, and enabled them to attract stable funding through Medicaid, the State Children's Health Insurance Program, and private sources.7 The Center for Health and Health Care in Schools, located at the George Washington University, is continuing this work by providing technical support to school health programs around the country.
  • The emergency response system. In the early 1970s, the Foundation funded a demonstration program that sped the development of the 911 emergency response system. Thereafter, President Gerald Ford signed legislation establishing a national emergency response system, based on the Foundation's work.8
  • Long-term care insurance. In the 1980s, the Foundation began funding the development of public-private partnerships between insurance companies and state governments to make long-term care insurance more affordable and accessible. The policy research, demonstrations, and advocacy that began in four states recently paid off when the Deficit Reduction Act of 2005 authorized expansion of these partnerships to all fifty states.9

Even though the Foundation was often far from the sole actor in these examples, our leadership, funding, and persistence helped turn the flywheel of change. The best foundations have often been among the first pushing when the wheel is hardest to turn and is building momentum. As others join in, it picks up speed and energy. Many times, and I think appropriately, we curtail our financial commitment at that point.

In visiting dozens of impressive programs, I have often reflected on the momentum of the flywheel and how the Foundation can ensure continued momentum, even as our financial support declines. Many programs have been successful in developing innovative approaches to significant problems, achieving their goals, and attracting considerable attention. However, their potential for enduring impact has not been completely realized, and we will not understand their full effect for many years. We have to stay connected, enhance these programs by using our credibility on their behalf, and disseminate their results to teach others.

Fourth, and finally, an especially important lesson is reflected in the Foundation's third Guiding Principle that commits us to lifelong learning and continual improvement.

Collins says it this way, "No matter how much you have achieved, you are always merely good compared to what you can become. The moment you think of yourself as great, the slide to mediocrity will have already begun."

We are proud of improving the health of Americans through our work to develop leaders, nurture the field of health policy research, reduce the prevalence of tobacco use, and change the way people think of end-of-life care—to name the most frequently cited. We can be even better—even great—if we stay focused and disciplined about achieving tangible results and keeping all cylinders of our engine firing to turn the flywheel.

Princeton, New Jersey
June, 2006

Risa Lavizzo-Mourey
President and CEO
Robert Wood Johnson Foundation

Notes

  1. Schroeder, S. A. "Foreword." To Improve Health and Health Care 1997: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1997.
  2. Collins J. and Porras, J. Built to Last: Successful Habits of Visionary Companies. New York: Harper Collins, 1994.
  3. Collins, J. Good to Great: Why Some Companies Make the Leap . . . and Others Don't. New York: Harper Collins, 2001.
  4. Collins J. Good to Great in the Social Sectors: A Monograph to Accompany Good to Great. New York: Harper Collins, 2005.
  5. Lavizzo-Mourey, R. "Foreword." To Improve Health and Health Care, Vol. IX: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 2006.
  6. Bronner, E. "The Foundation and AIDS: Behind the Curve but Leading the Way." To Improve Health and Health Care, Vol. V: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 2002.
  7. Lear, J. G., Isaacs, S. L., and Knickman, J. R. (eds.) School Health Services and Programs. San Francisco: Jossey-Bass, 2006.
  8. Diehl, D. "The Emergency Medical Services Program." To Improve Health and Health Care 2000: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass, 1999.
  9. See Chapter 5 of this volume.
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