Making BHAGs Possible With OKRs

by Ali Khan

Making BHAGs Possible With OKRs

by Ali Khan

Possible has improved healthcare in Nepal by using BHAGs to maximize their OKRs.


A. Khan
Published on 05.09.2019

“Doing global health work,” notes former Possible CEO Mark Arnoldy with a chuckle, “often feels like firefighting with a water pistol.”

He’s not wrong. The brutal truth: the health space is delightfully messy on a good day and often confounding the rest of the time—as countless patients, policymakers, entrepreneurs, impact investors, families and health professionals can attest. The same rings true for both high-growth companies and high-impact social organizations. Possible, of course, happens to be all three.

Even amid a sea of organizations with big hairy audacious goals (BHAGs), however, Possible’s mission is particularly hirsute: In everything we do, we believe it’s possible to deliver high-quality, low-cost health care to the world’s poor.

Courtesy of Possible HealthCourtesy of Possible Health

But the team at Possible aims to go big or go home. Through a novel mix of governmental partnerships in quality improvement, home-based care delivery by community health workers and research-driven policymaking, Possible is out to transform the health of nations.

Gaurav Tiwari, Possible’s Nepal-based operations lead, captures this sentiment beautifully. “Possible set out to achieve its goals in a completely different way—a radical approach that was ambitious enough to not just deliver what we set out to do medically, but to have a view of helping like-minded people do things differently, and change the policy landscape in the country.”

Conceived by a team of passionate Yale medical students and public health professionals in 2006, the U.S.-based non-profit, together with its Nepal-based NGO arm, Nyaya Health began in the aftermath of a civil war. After years with very limited job opportunities in rural Nepal, Nepali men were beginning return home after years of traveling far and wide to find work. Unfortunately, they didn’t come alone—many brought HIV with them. Nepal quickly found itself in the throes of a rural HIV epidemic, with little healthcare infrastructure to address it.

Into this void stepped the Possible team. “The work started very humbly,” says Arnoldy, “It started by renovating a grain shed, converting it into a clinic, and bringing some qualified certified healthcare practitioners back to the region.”

Courtesy of Possible HealthCourtesy of Possible Health

Firefighting was part of everyday life. Candidly, says Arnoldy, “it was all-out chaos. You're always trying to figure out how to squeeze as much as you can out of what you have, and the tradeoffs are particularly difficult when you're dealing with human health.” It was audacious simply to ensure if there was enough medicine in stock. Now a team of volunteers working on side projects from their desks and hospital bedsides were coordinating between Boston and Nepal to build and run a decent three-room clinic—their first local base of operations—from scratch.

They succeeded. In fact, the clinic was received so well by the community that the infrastructure and the team needed to grow rapidly to support demand. That’s when Arnoldy came aboard as Possible’s first full-time leader in the organization. But success—in the form of seven-figure annual grant funding and an average of 100 new employees over two consecutive years—led to new complexities.

“We needed to determine, quickly, what we were measuring—and why,” Arnoldy says. “We looked for ways to turn that chaos into something more deliberate.”

That search lasted until 2014—when he stumbled upon John Doerr’s original presentation to Google about OKRs (Objectives and Key Results).

Photography by Paul BarberaPhotography by Paul Barbera

When OKRs met Possible

As he delved into OKRs, Arnoldy felt as if he’d found the answer to the fears keeping him up at night. Their appeal was immediate: setting stretch objectives—and focusing deeply on the key things that would make those goals a reality by measuring them continuously—aligned beautifully with Possible’s innate audacity. But for Possible, an organization so committed to the creation and maintenance of great teams that it wrote its own For-Impact Culture Code, OKRs also offered the promise of a management system that would amplify, not stymie, their culture.

Possible took a page from other high-growth ventures implementing OKRs for the first time. The senior management team tested it out for a few iterations, refining it for their needs before rolling it out to the rest of the organization. Possible’s ground rules would make John Doerr proud:

  • Stick with 3-5 Objectives
  • Make Key Results ambitious–they should feel somewhat uncomfortable
  • Make Key Results quantifiable
  • Strive for 70% success in your OKRs
  • Make OKRs highly visible

The incubation experience, as Arnoldy notes, was immediately humbling. “It revealed the tendencies that we were sort of mindless about.” Indeed, the task of converting Possible’s lofty BHAGs into actual OKRs with tangible measurement caused many senior leaders to step back. They were challenged to apply “useful realism” to their vision, developing the discipline to get very specific about how to translate goals into reality and to plan around obstacles. Although OKRs were on, Arnoldy recalls, “OKRs became really central to engaging in the learning process at the end of the quarter, midway through the year and at the end of the year.”

Over the course of the first few OKR cycles, Possible’s leadership added a new ground rule: Note what is purposely left out of your OKRs. Acknowledging and discussing this enabled them to collectively commit and remain focused on their top priorities, and reduced their tendency to overload their plate.

Courtesy of Possible HealthCourtesy of Possible Health

What OKRs Help Make Possible

And though it’s not often that OKRs can be directly attributed to turning the seemingly impossible into the real, that’s exactly what’s happened with Possible. From 2014 to 2018:

  • Possible’s clinical presence in Nepal grew from one hospital and one clinic to multi-clinic, multi-hospital operations across the country;
  • Possible teams cared for over 600,000 patients (since launch), growing annual patient engagement from 56,000 to over 112,000 from 2014 to 2016;
  • The organization’s annual operating budget quadrupled to over US $6 million;
  • Clinical outcomes in surgical complication rates, chronic disease management and control, postpartum contraception prevalence and births in hospitals and other institutions all made steady, best-in-class improvements; and
  • Possible grew from 93 employees to 247 employees in a two-year span.

The discipline, focus and execution driven by the OKR framework–and the shift from reactive to proactive management on a day-to-day basis–enabled Possible to step away from the constancy of firefighting in health. What’s more, OKRs enabled Possible’s leadership team to actually do what it said it would do-and to make promises that it felt it could actually keep.

As Possible began to cascade the OKR approach across the rest of the organization, however, Arnoldy, Tiwari and other leaders suspected the process wouldn’t be so straightforward. As the Nepal-based team at Nyaya Health began implementing OKRs, they faced myriad geographic, cultural, linguistic, educational and technological barriers.

Simple? No. Possible? Yes. We’ll share more about how in the coming weeks.

Ali Khan, M.D., M.P.P. (@alikhan28), is a Chicago-based physician, health innovator and social entrepreneur working to transform healthcare for the most vulnerable.

Courtesy of Possible HealthCourtesy of Possible Health

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