Failure Report: Year 2011 (Part 2 of 3)
May 22, 2012 by Jeremy · Leave a Comment
The only bad failure
is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do!
But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.
The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
The three major failures of 2011, to be covered in this series of reports are:
Failure #2: High-mortality Remedy Missions in February/March 2011
Failure #3: The Loss of Our Sulaymaniyah, Iraq Surgery Site as a Major Developmental Partner; Lack of Surgical Capacity Increase As a Result of Remedy Missions Conducted
Let’s get started…
2011 Failure #2: High-mortality Remedy Missions in February/March 2011
In February and March we ran two back-to-back Remedy Missions. One was our second in the southern city of Nasiriyah; the other was our second in the northern city of Sulaymaniyah.
Over the course of four weeks of surgery, mortality rates between the two cities reached 20.5% (7 deaths out of 34 operations).
A few of the losses were very surprising to many on the local and international team and had an extremely demoralizing effect on the team (particularly in Sulaymaniyah). The loss of momentum undoubtedly had a qualitative impact on the care provided as the trip progressed.
Some of the factors were anomalous, such as our lead surgeon contracting an infection in a wound on his ankle that resulted in impromptu surgery inside Iraq to save his leg. But other factors were almost certainly preventable, beginning with case selection and moving to fundamental deficiencies in the hospital equipment and protocols themselves.
A lack of warming blankets, portable oxygen units, a ready blood bank and several other fundamentals led to a less-than-ideal environment for the teaching of pediatric cardiac care. As a result of all these factors and the inherent difficulties of open-heart surgery, mortality rates in the Sulaymaniyah mission reached 22% (four deaths)—unacceptably high by any standard.
None of the deaths were considered “surgical” deaths, in the sense that the child did not die on the operating table, but rather in the post-operative intensive care unit, ward, or—in one case—in the car on the way home after being prematurely discharged by a local nurse the day the international team left the country.
Lessons Learned:
Our international team was very impressed with the local cardiologist for Remedy Mission II in the southern city of Nasiriyah. When it came time to schedule Remedy Mission III in that city, the decision was apparently made to not send a cardiologist on the mission, believing that the local team could handle it. This may have contributed to the imbalanced case selection in RM III and may have led to the situation in which three children died during the course of the mission.
Since that mission, an international cardiologist has been present on every Remedy Mission in an effort to help with case selection and create a balanced schedule of surgeries.
In Sulaymaniyah for Remedy Mission IV, case selection was complicated by the number of stakeholders in the mission. Children were formally and informally (that is, “politically”) put into the mission by the Preemptive Love Coalition, local cardiologists and surgeons, Kurdistan Save the Children (a local NGO), and the Health Directorate.
With regard to Yahya’s case, as described before, I can certainly say that my judgement was impaired when it came to case selection. I can speculate that other entities, in an effort to do right by the friends and patients on their lists, made similar errors in judgement that ultimately skewed the balance of the surgery schedule and its complexities.
When two children died in Sulaymaniyah after the international team left for the airport, we realized for the first time how ill-equipped the local team was to handle relatively simple post-operative care (one child had a positive prognosis in the ICU and the other was already out of ICU and recovering in the ward).
In our post-mission Impact Evaluation Report, we published the following statement:
Our post-mission conferences and deliberations on the matter resulted in the following protocols:
1. A mandatory reduction in “RACHS-1 scores” presented to the international team by the local team
2. A mandatory international ICU team to be left behind after surgeries stop to stave off post-mission ICU deaths and errant discharges
3. A postponing of our next planned mission to the Sulaymaniyah Center for Heart Disease due to lack of preparation of materials, equipment, staff, and protocols
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Failure Report: Year 2011 (Part 1 of 3)
May 3, 2012 by Jeremy · Leave a Comment
The only bad failure
is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do!
But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.
The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
The three major failures of 2011, to be covered in this report are:
Failure #2: High-mortality Remedy Missions in February/March 2011
Failure #3: The Loss of Our Sulaymaniyah, Iraq Surgery Site as a Major Developmental Partner; Lack of Surgical Capacity Increase As a Result of Remedy Missions Conducted
Let’s get started…
Failure #1: Leadership Indecisiveness on the Case of Six-Year-old Yahya
This was a major lesson in leadership that potentially affects every area of our organizational and team life, couched in the saga of one very specific family.
I was walking home from work one night in Iraq in early 2010, when my phone rang. On the other end of the line was a man, knocking on the door back at my office, in hopes of meeting me and presenting the case of his nephew, Yahya, to me for surgical consideration. I asked if we could meet tomorrow, but he was insistent and there seemed to be great urgency in his voice. Instead of postponing the meeting, I gave him directions to my home and met with him over tea.
From early on, the situation was less than ideal. Yahya had already received one charitable heart surgery and the second one that was being requested was bound to be difficult.
In our 2007-2010 Failure Report, I noted our decision to restrict the complexity of children we sent abroad for surgery after a series of deaths caused us to reconsider our risk tolerance. Yahya was definitely on the high end of our new risk tolerance.
I chose to refuse surgery to the family based on our new priorities.
Months later, after a new check-up, Yahya’s mother and father brought him into our office to inquire again about the possibility of surgery. I’ll never forget sitting with them in my office explaining our decision to decline surgery funding for Yahya.
Then, with all the persistence that you would expect from a mother, she appealed to me again not to turn away their little boy.
I think one thing that non-profit directors and program directors fail to say often enough is this: “I am a human. I’m swayed by the kindness or brashness of our patients and, at times, it heavily influences how I make selection decisions.”
I could not continue to say “no” any longer. I said “yes” (with conditions).
Our surgeon in Istanbul was clear from the beginning that his surgery would require a “valved conduit” (an additional $5,000 expense or more) and licensing agreements in Turkey at the time had caused a shortage of such devices.
Cody Fisher (Development Director) did a great job reaching an agreement with Medtronic providing Yahya with a donated conduit, but the timing of receiving the conduit was still beholden to the licensing agreements that were being worked out in Istanbul.
All these factors together ultimately led to Yahya missing our July 2010 surgery group to Istanbul. We refunded the family’s portion of the money they had contributed for his surgery.
Shortly thereafter, in August 2010, we conducted our first Remedy Mission inside Iraq—our new programatic focus on localized training and development. The mission was such a huge success, I became convinced that we needed to cease all funding for outside surgeries and focus solely on development work inside the country.
But I also felt a sense of commitment to Yahya and his family, who were basically caught in the transitional period between one programatic focus and another.
What I should have done at that point was send Yahya to surgery in Turkey, finish our commitments there, take the free valved conduit from Medtronic, and finish our work in Turkey strongly. What I did instead was place Yahya on an upcoming Remedy Mission and take the Turkey option off the table for the family.
What I didn’t account for very well in that decision was how the complexity of Yahya’s case would fare in a development setting; a setting in which local capacity was far below that which he would have received in Istanbul.
In the chaos of Remedy Mission IV, a number of things went badly. Among them, Yahya’s family probably did not receive the proper explanations that they should have about the risks of his surgery and they probably felt very vulnerable about the decision to go forward with the risky surgery or forever miss their opportunity.
It was difficult to assess all this in real time, in part because I was so hopeful for Yahya and his family. In my optimism, I did not see or recognize a few red flags. But even that is not the whole truth… I remember hesitations—“red flags”—even as I sit here today. I willingly suppressed anything that was not hopeful and optimistic. It seemed noble, brave and right.
But he wasn’t my child.
Yahya’s surgery presented many complications that ultimately required doctors to operate through the night. When Yahya arrived in ICU around 5 or 6 a.m. the next morning, he was deemed stable enough for the surgical team to go to the hotel for a few hours of sleep. Before their bus even arrived at the hotel, though, Yahya had passed away in ICU.
I would not normally include a single death in a year-end Failure Report. My point is not that I feel bad and need catharsis. It’s just that Yahya was different, and not only because he had a name or because his family hosted us for dessert in their home and shared tea in mine. No, Yahya was different because I flipped-flopped on the family so many times. I said “no.” Then “yes.” Then “no” again. And then “yes.” And then he died.
Organizationally, the failure was related to a lesson we were just beginning to identify in our 2007-10 Failure Report: we are not the best qualified to select children for surgery. The suggested way forward at that time is still right: we have handed child selection over to a committee of local healthcare providers and our international surgical team. There will still be deaths that we regret deeply, but they will be less a function of our role and influence in the child selection process.
Personally, the failure was related to my inability to make a decision and stick with it. I always had a bad feeling about Yahya’s likelihood to endure surgery. That was why I denied funding more than a year prior to his death. I had good reason to deny funding. But I went back on my hunch. Fair enough… I wanted to give a family a chance. But I never really got over my fears of his death and that made me unwilling to go all in with the family. I hedged over spending extra money on his expensive valved conduit. And even when the conduit was donated, I found other reasons to delay surgery for fear of spending a lot of money (including the family’s) on a surgery about which I was always suspicious.
Lessons Learned:
1. It’s OK to change one’s mind; but a leadership “Yes” or “No” should mean something. It hurts everyone involved to say one thing, give the impression of support, and never fully get behind one’s own decision. In this case, it played a role in Yahya’s death. He may have died in Istanbul just the same. The death itself is not the failure here. The faulty, character-flawed process by which I made life-altering decisions is.
I said “no.” I should have stood my ground. Or I said “yes” and I should have given that family my fullest “yes” ever. Instead, I said “yes” and stayed on the fence. I won’t do that again.
2. We are not qualified to select children. We are too emotionally attached and we do not possess the knowledge to make a right decision about a patient’s candidacy for surgery. We have handed child selection over to a collaboration between local cardiologists and our international surgical teams.
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Our Struggle With Mortality
April 10, 2012 by Jeremy · Leave a Comment
When you intend to be in the “business” of saving lives, facing up to death can be a difficult thing.
For my part, in leading the Preemptive Love Coalition, knowing how to admit “failure,” when to acknowledge death without assigning fault, and when to let a death go unreported can be very difficult. The inherent difficulties are compounded by my responsibilities to various constituencies, including (but not limited to) the parents, local health care professionals, local political realities, coalition partners, national political realities, and international donors. At any given time, any one of these entities could be pushing for more or less reporting on a specific item; on a specific death and data set that would include a specific death.
In our January Remedy Mission VIII, a little boy named Yousef that we had grown to really love died in surgery. We held him up as a beacon of hope for the future of all Iraqi children facing congenital heart disease. We told his story and proudly proclaimed his desire to be the next world-famous soccer player. And then we asked you to give your money so that he could be saved by a team of international doctors and nurses. We also promised that his surgery would be an occasion for still more training for Iraqi doctors and nurses in our Nasiriyah program in southern Iraq during the mission (which was to be our sixth mission to the center in just 13 months).
Without exposing ourselves to legal action for disclosing confidential information, it will suffice to say that a local trainee made a mistake that cost Yousef his life.
Because Yousef was the first child in line for treatment that mission, we questioned what the psychological impact would be in widely reporting his death. Again, our considerations involved our international volunteers, local politics, coalition partners and international donors most specifically.
Remedy Mission VIII also featured two first-time nurses from the International Children’s Heart Foundation, both of which provided excellent insights into the local situation and helpful critique about the lack of success and development in the Nasiriyah program.
As we struggled to understand the death (the first mortality in 2-3 missions), our focus was on program development and responses to the conditions that led to the fatal error. Once the mission was over, a few more children had died and reporting on any single one of them was basically more than any of us could stand to emphasize at the time.
A typical response from a surgeon might be “Children have to die in order to build a heart surgery program.” And it’s true. But we are not surgeons. We are just a few normal people who have not held the human heart in our hands and who have not trained for this.
I’m writing to apologize for not reporting on Yousef’s death. We sent a private email to all who donated to Yousef’s account and let them know. But we did not endeavor anything more public.
After the mission a close friend who was still praying for Yousef contacted me without knowing he had died. It was then that I realized how many friends Yousef had and realized that it is not donations alone that tie us each to these children we seek to help. We are drawn in by their eyes, their stories and the hope they exude.
I wish now I would have allowed you to mourn Yousef’s death with us. They are not always easy decisions when juggling the preferences of so many stake holders. But somewhere along the way I gave up trying to push the message out because I did not want to come face to face with the story of his death again.
When you’re in the business of saving lives, “almost” doesn’t count.
We miss Yousef. He was a bright light!
And there are many other children out there who need our help; who are likely to survive; who can greatly benefit from surgical intervention. And there are hundreds of doctors and nurses who desperately need to be trained so they can serve these children on their own.
Thank you for continuing to stand with us…
Jeremy
Please feel free to email me with any questions or concerns.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Three Ways Our Vision Was Too Small—And How It Has Matured (Part 2 of 2)
April 3, 2012 by Jeremy · Leave a Comment
In my previous post I confessed three ways we got our vision wrong in the early days and touched upon how we’ve seen our vision mature along the way. Here I want to actually tell you what our vision is today. It is not perfect, but neither is it final. We will continue to learn and allow ourselves to be shaped.
We envision a future in which all Iraqi children have access to the lifesaving heart surgeries they need within two hours of home.
There will still be an old backlog for a decade to come. And there are many obstacles to overcome that are beyond our immediate realm of influence (a nationwide dearth of anesthesiologists and nurses, for example).
It is our mission to eradicate the backlog, only now the ”why” behind the “what” is more nuanced and mature. The backlog will be eradicated by the hands of the doctors and the nurses we train. The country probably needs 10 heart centers performing 500-1,000 surgeries per year. We hope to be involved in saving lives and training locals in as many of those sites as possible so that every child with a heart defect has access to the lifesaving surgery they need within a two hour drive of their home.
Why so many centers? Why not settle for all children flying to Baghdad for the surgeries they need? Because the backlog is too great and the long-term forecast is too dim for one or two expert hospitals alone. The nation requires regional solutions. A single expert center in Baghdad will not suffice.
Today we have active programs in Nasiriyah and Najaf—sites that collectively serve a population roughly the size of Chicago, Los Angeles, Philadelphia and Houston. Before the end of the year we hope to begin healing children in Fallujah, Basra and Dohuk as well.
And this is not just our vision. This vision developed in conjunction with Iraqi doctors, governors and health care directors from across the country. At present six additional cities across the country have requested the assistance of our Remedy Mission teams. And the Iraqi Ministry of Health is extremely invested financially in the success of this collective vision.
For all the questions that remain, we let this collective vision guide us: a future Iraq in which all children have access to the lifesaving heart surgeries they need within a two hour drive of their home.
We will need your help realizing this vision. It won’t be easy to establish heart centers within two hours of every population center in the country. But it will unmake violence and remake the worlds of thousands of Iraqis whom we love and live to serve.
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If you have any questions or comments regarding the development of vision or anything I’ve said in this or in my previous post on vision, please email me at your convenience. I would love to hear from you.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Three Ways Our Vision Was Too Small—And How It Has Matured (Part 1 of 2)
March 27, 2012 by Jeremy · Leave a Comment
A few weeks ago we ran a short series on cultivating vision… these posts were not perfunctory. They were, in fact, my own practice of establishing the Preemptive Love Coalition with my wife, Jessica, and Cody Fisher.
In our earliest days we said our mission as an organization was to “eradicate the backlog of children in Iraq waiting in line for lifesaving heart surgery.” But the best visions and missions are dynamic, almost alive; they mature. And we are excited to bring you along in our vision as it has matured in recent months.
We have learned a lot more about this field in which we work than we knew when we started out. Additionally, the country and the individual regions of Iraq have changed drastically since we arrived. There were numerous occasions in which we said, “Does our mission still fit?”
Below are three ways in which we realized our vision was “off”:
#1: The Math—How We Saw the Problem
The math does not add up for us to “eradicate the backlog” on our own. Indeed, our vision in 2007 had largely to do with 700 known children in one Kurdish province who were in need of surgery; we now know about thousands waiting in nearly every one of Iraq’s 18 provinces. And we estimate 6,000-11,000 new children annually are born in Iraq with congenital heart defects.
How we see the problem determines how we shape our vision for the future. A problem with 700 localized constituents might warrant one vision. A nationwide problem with perpetuity and tens of thousands of constituents likely calls for a different vision altogether.
#2: The Method—How We Addressed the Problem
Local doctors set the stage by telling families there were no solutions in Iraq for their children who needed heart surgery. That was true. So families, local development experts, political figures and doctors all asked us to assist by sending children outside the country. On the one hand, we met a real need. On the other hand, we lacked imagination and delayed the development of long-term local solutions. It took us almost three years to imagine and implement our Remedy Missions—a far better use of resources to create local-led solutions for this local problem.
#3: The Message—How We Talked About Solutions
Because we began by exporting the Iraqi congenital heart disease problem to others countries, we largely failed to factor local healthcare experts into our vision for the future. We worked with one local cardiologist, but when we talked about our solution for “eradicating the backlog”, we largely talked about you—the donor—and how you were the solution to all the ills facing these dear families. We set up web pages and called on you to save the lives of children like Aras, Shad and Nivar. We still call on you to help save lives—but we feel much more keenly today that our message has matured, because our methods are finally dependent on locals. And that has happened because both statistics and ethics compelled us to see the problem differently.
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In part two of this post we’ll actually articulate our vision as it has matured. Come back next Tuesday to read more. In the mean-time, why don’t you contact me with your own thoughts and stories about vision? Please email me at your convenience. I would love to hear from you.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Failure Report: Years 2007-10
March 20, 2012 by Jeremy · Leave a Comment
The only bad failure
is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do!
But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.
The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
Failure #1: Inability to Overcome the High Costs of Buy Shoes. Save Lives.
Since our founding program in 2007, the Preemptive Love Coalition has proven that we are willing to try new methods, forge new ground, and break ranks with low-impact or failed policies and programs.
In 2007, we launched our successful Buy Shoes. Save Lives. program—a hybrid micro-economic-meets-social-enterprise model from which we used profits to fund our first lifesaving heart surgeries for Iraqi children. At the time, the U.S. was eager for good news coming out of Iraq and we hit the ground with exciting revenues and no debt. By 2009, however, a lot had changed in America and it was obvious that the BSSL program no longer provided the same return on our investment (read: not worth the work).
We endeavored to shake up the product model that had been employed for more than 3,000 years by local artisans. But local resistance proved greater than our savvy or financial incentives. Moreover, the rise of other prominent shoe-based companies (most notably TOMS shoes), ate into the market share and caused both expectations and misconceptions that were difficult to overcome. As a result, we significantly scaled back BSSL production and focused on the creation of different revenue models.
Lessons Learned:
1. Market forces (in every sense) can drastically affect the funding of social programs—especially when tied to a luxury item like $120 hand-made shoes.
2. BSSL served us well and launched us into the space we then occupied in Iraq. But BSSL was never likely to be the financial engine for long-term development in a country like Iraq. We knew that within the first six months and began planning accordingly.
3. Adapt. Keep no sacred cows. Keep innovating.
Failure #2: Delaying and Denying Local Development by Exporting Surgeries
Due to the nature of our network at the time of our founding—and owing to the fragile state of Iraq at the time (including the political hegemony that had been set up at the Ministry of Health)—it was impossible to conduct lifesaving heart surgeries for children inside Iraq. A handful of organizations worked together to send children outside the country to nearby (then far-flung) countries.
From 2007-2009, we exclusively sent children outside Iraq for surgery. We saved more than 50 lives and earned a strong reputation in parts of Iraq for being an organization that would take a chance on children who nearly every other organization would prefer to leave behind.
By 2010 it became obvious that the infrastructure and political situation inside Iraq had changed substantially. We began exploring opportunities to bring surgical teams into Iraq in an effort to provide local development and create economies of scale of our export model.
It’s difficult to call the 2003-08 “exporting” model a failure, in part because it seemed so necessary at the time as a stepping stone to something greater. But there definitely came a time in 2009-11 where exporting children to surgery as a primary model of intervention became a failure (in our opinion) for all who kept practicing it primarily.
Lessons Learned:
1. Always prefer long-term, local solutions.
2. Aim to accomplish more for less. We averaged $12,221 per surgery in FY 2009 (a year in which we were solely responsible for all contracts on “exported” surgeries). In FY 2010, the first fiscal year in which we imported solutions through our new Remedy Mission program (and a year in which we still sent five children abroad for surgery), we reduced the per surgery price to a mere $2,222. And that amount did more than buy us a surgery, it bought us hands-on training for local ICU nurses, heart surgeons, and technicians, hastening the day of a fully functioning heart center in two different cities in Iraq.
Failure #3: High Mortality Rates Due to a Underdeveloped Selection Process for Surgeries Done Abroad
Of the 31 children for whom we assumed complete selection, logistical and financial responsibility in FY 2008 and FY 2009 (rather than funding through partnerships elsewhere), six died.
No program aims for a 19% mortality rate; especially when operating in world-class hospitals at $12,221 per surgery. Emotions can cloud vision. Everyone from the organization to the family, the donors and the doctors were looking for a win. We wanted to believe that we were a standard of compassion to be emulated by all—we were the ones who took last chance children.
There was some truth in that. We were supported by doctors who believed in a family’s right to decide and who genuinely wanted to give a chance to anyone and everyone.
But there was pride as well. We believed that somehow other organizations lacked vision or compassion for rejecting children who were deemed “inoperable” (a word that can mean different things to different parties).
By the time February 2010 arrived, we were very aware of our high mortality trend and began to seek outside counsel on our selection process in an effort to create distance between the actual service providers and the local healthcare referrers inside Iraq. These conversations led us to ease up on the complex cases we were willing to accept and paved the way for a mortality-free stretch from Feb – Dec 2010 in our surgeries done abroad (11 surgeries; 0 mortalities).
Lessons Learned:
1. Pride goes before a fall. There were good reasons that other organizations had implemented selection policies that were more stringent than ours. We had early success accepting a few children who were deemed “inoperable” and we let an unhealthy narrative set in that allowed us to believe that we were more compassionate than others. Of all the failures we’ve experienced to date, I think this failure—and the lesson associated with it—is among the most profound.
2. When the only metric for success is life or death, it is helpful to build a firewall between service providers, funders, beneficiaries, and logistics personnel.
Conclusion:
We have had an excellent run leading up to this point, with scores of lives saved and countless stories of peace and reconciliation coming among the various friends we’ve served. But our entire website is mostly dedicated to telling those successes and celebrating the role of our donors and partners in each one. This report is necessary because failure is inevitable. We neither want to hide nor fixate on our failures. But we do want to purposefully take an account of them, learn from them, and report to you how we are moving forward in light of lessons learned.
Moving forward, we will be focusing less on our Buy Shoes. Save Lives. program as a major revenue stream; we have ceased all donor-funded surgeries outside of Iraq; have recused ourselves from child selection; and have placed all of our focus on bringing in Remedy Mission teams to Iraq in an effort to accelerate long-term, local solutions.
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Three Ways to Pursue Your Vision While in a Holding Pattern
February 3, 2012 by Jeremy · Leave a Comment
Note: This is the third post of a three-part series on defining and achieving Vision. Click the links to read part one and part two.
I remember those early, heady days when we founded the Preemptive Love Coalition and we envisioned—for the first time—an Iraq free of the burdensome backlog of children waiting in line for heart surgery. I remember calling families to alert them that we could finally send their child to heart surgery, only to hear on the other end of the line a polite-but-devastated, “It’s too late. My child died yesterday.”
I’ve sat in different waiting rooms across the country where children were waiting to be seen by the doctor, and I’ve seen children die before my eyes—literally while waiting in line.
We’ve said from the beginning that our mission is to “eradicate the backlog.” But our vision, stated more positively, is that every Iraqi child would have access to the surgical intervention they require to thrive.
Since 2003 and the start of the war, an estimated 50,000 children have been born into The Backlog. There is no way of knowing how many were already alive and waiting in line before that time; nor do we know how many we have lost during that period nationwide.
In that time, while seeking to serve these children, we have faced bombings, death threats, the imprisonment of our staff, armed conflict in the cities where we’ve worked, political roils, funding crises, and partnerships that have turned predatory.
The minefields you will have to endure while pursuing your vision are complex. All the easy stuff has been accomplished already! The things that remain are usually fraught with risk and even danger. Depending on your context, it will become impossible at times to move forward with your vision at all.
So what do you do when you are placed in a holding pattern? Like these Iraqi children I’ve sat with and held, the “waiting room” is where many a vision has died. Visions need activity. They need momentum. They need progress.
Below are three things I’ve consistently done to nurture vision while stuck, for reasons beyond my control, in the waiting room.
1) Plan. Whether the vision you are nurturing is one for your marriage, your children, your business, or some social issue across the world, nothing gets done well without planning. When you start to become dissatisfied with the world (marriage, business, etc) as it is; when you start to envision a better way to live or a solution to one of the world’s intractable problems, you must begin to plan.
Planning means different things relative to the vision in question. It might mean quiet research on the problem itself. It might require a lot of info gathering about proposed and enacted solutions currently in the marketplace. If the problem is really so bad, why has no one else tackled it yet? What are the obstacles to success? Is the space crowded with solutions already? What would you need to do in order to bring something new to the field? What will it cost if it all goes well? What will it cost if it all goes terribly?
Woe to the visionary who jumps in without planning. The waiting room is one of the most important places for a vision to begin, as it gives us time to make our missteps on paper before ever spending a dime or wasting the time of others in the real world.
2) Position. I’ve met many people along this journey who want to eradicate poverty, provide clean water, transform social problems across Iraq and the Middle East, etc. Among the worst things I’ve seen passionate visionaries do is a chronic failure to become well-positioned in the field of choice so that expertise and solutions might flow more naturally.
A well-intentioned twenty-something starts a new non-profit organization out of Idaho to help Darfur. A well-to-do family from the suburbs launches a ministry to the homeless downtown. A businessman seeks to change industries and launch a new venture at the invitation of a friend.
Sometimes these things work well enough. But if you are pursuing a vision for the future as it should be, and not merely as it is, you must position yourself for the desired change.
Whenever possible, I advocate networking and proximity. Trying to engineer a vision for another part of the world from the comfort of your living room in America is usually a bad idea. A reliance on internet material instead of diverse, first-hand accounts from your customers or constituents just won’t cut it. Whether you are in business or in international development—indeed even as a parent or a spouse—vision is about meeting the needs of others. We must be in a position to accurately understand the needs of those for whom we are pursuing our vision.
When the waiting room keeps you from fully acting upon your desired vision, sometimes the best thing you can do is move your body; get closer to the action; and hold more meetings with all relevant parties to ensure that you deeply understand the issues affecting them.
3) Pray. I won’t spend my time on a vision that I can accomplish on my own. Anything small enough to be accomplished by me, without the intervention of God, is a task that I am happy to forgo and leave for someone else.
When I pursue vision, I choose to work on things that overwhelm me and cause me to go to God in prayerful dependence. In fact, one of the greatest things for me about pursuing vision is the act of worship that it can become; not worship of the vision itself, but worship of the God who alone can sovereignly work through human freedom to bring about a better future.
I realize not all readers and visionaries will agree with me on this point. But when I am sitting in the waiting room of vision (or riding the wave of visionary success, for that matter), I commit myself again and again to God who hears, who cares, and who proactively works in this world to set all wrongs to right.
The snares that lay in wait for you on your journey to fulfill your vision are beyond number. The delays and unexpected detours have caused the death of countless visions and visionaries. Planning, positioning and prayer are neither exhaustive nor fool-proof, but without these disciplines, my vision that every Iraqi child would have access to the cardiac surgical intervention they require to thrive in childhood and become fully-contributing members of society would have long-since died in the many waiting rooms that have beset us along the way.
Are you in a holding pattern? Are you waiting on details to be clarified? Is your how still taking shape now that you’ve defined the what of your vision?
Keep planning, get positioned, and by all means I commend to you the God Who Cares.
These things are not passing. They are still a part of the active pursuit of your vision. Do you see it differently? Do you have other disciplines you use when stuck in one of life’s waiting rooms? I would love to hear about it. Send me an email by clicking this link.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
On Vision: Defining The “What” Before The “How”
January 30, 2012 by Jeremy · Leave a Comment
Note: This is the second of a three-part series on defining and achieving Vision. Click here to read the first part of this series.
I was sitting in an Iraqi hotel lobby in 2007 when one of the hotel staff who was serving me tea approached me and asked: “Can you help my cousin? His daughter was born with a hole in her heart, and no one in all of Iraq can help her. Please, can you help?”
I had just moved to Iraq with my family to work with a different NGO. I didn’t know anything about heart surgery for children or anything about taking children to other countries for treatment.
From the beginning, helping this little girl seemed impossible. And she wasn’t the first child I’d met in Iraq with a life-threatening heart defect. In fact, it seemed like almost everyone knew someone with a child who was born with a messed up heart.
My work with the organization I was with was not capturing my heart. It seemed to lack both vision and impact. And, in any case, it was not set up with an exit strategy—there was no developmental finish line.
Around the same time, Cody Fisher began telling me of his NGO work with many of these children in need whose files were piling up on his friend’s desk as she sought to find them heart surgeries outside the country. The more I inquired, the more intrigued I became.
I learned that there were seven hundred children within a two hour drive of our city who were waiting in line for lifesaving heart surgery. You would never find a backlog that large anywhere in America!
Over the course of this journey, my wife, Cody Fisher, Michelle (then Bailey) Fisher and I chaffed under the tyranny of life as we knew it in Iraq.
After all, it seemed that many of these heart defects were not simply occurring naturally but were probably directly attributable to acts of war—both martial and economic. This was an issue of justice. As Americans, we felt directly responsible for some of this. But it was primarily as Christians that we decided to jump into the unknown and commit ourselves indefinitely to the cause.
Defining the cause itself could have taken us a number of different directions. I am grateful to God that we got this one right amidst all the unknowns: we defined the what before the how.
Would we create an organization primarily because Jeremy had met a little girl in a hotel lobby? No. Would we create an organization primarily because Cody had a few connections to get us off the ground quickly? No.
From the very beginning we established a vision that was far more grand than anything else in cardiac care nationwide.
“… to eradicate the backlog of Iraqi children waiting in line for lifesaving heart surgeries.”
Looking back, it was ludicrous. It was naive. But it was never a mere “dream.” It was a vision. (See my last post on my differentiation between a dream and a vision). There was a moral conviction behind it. It would never be enough for us to simply help the children who crossed our path. It would never be enough to clear the files or the “backlog” on our desk. We had to exist for all the children of Iraq who were waiting in line for lifesaving heart surgery.
Months after articulating our vision for a Backlog-free Iraq, I learned that the leading expert in the region had actually dumbed down the number of children waiting for surgery because he did not want to scare us off. The number was actually 5X greater—closer to four thousand children. We were still waiting on estimates from the rest of the country.
We started to suspect ten thousand children or more were waiting for surgery. And we were not smart enough at that time to really question how many new children were born into the country each year in need of heart surgery.
We were almost immediately faced with a crisis. Our 20-child per year pace was never going to “eradicate the backlog.” Our methodology—the how—could never see our vision realized.
Do we change our vision to meet our methods, or must we change our methods to meet our vision?
Nothing had changed in our desire to see Iraq free of a burdensome backlog. We had established our vision—our what—before we had a clear idea how we were going to bring it about. So we stuck with our vision and forced our methods to catch up.
We redoubled our commitment to eradicate the backlog. We personified “The Backlog”—for he was a devilish foe who needed to be vanquished by all the heroes like you who would partner with us in the coming years. The Backlog only existed because of injustice—both local and internationally imposed. To defeat The Backlog would be more than a triumph of our organization; it would be a victory for every family across Iraq, because every family across Iraq is susceptible to congenital heart disease, the number one birth defect in Iraq and in the world.
Our vision was still maturing, to be sure, but we got this one thing right: we established the what before the how.
There are other organizations that work into Iraq in an effort to help children with heart disease. But sometimes I wonder if the how has taken precedence over the what. Candid conversations often reveal a complete absence of vision; a settling for the methodology of today for lack of a compelling picture of the future.
Since our inception in 2007, we have made four major programatic (methodological) changes in an effort to stay the course and eradicate The Backlog. Every one of them was scary. Every one of them could have been a colossal failure. But vision demands innovation and risk.
Do you have a hard time accepting the world as it is? Do you feel morally compelled to work for a different future? Do you have a vision that you are currently nurturing or pursuing? If so, do yourself a favor: define the what before the how. Methods change with technology, culture and economics. Don’t focus on the how. Get your sweeping vision right by defining the destination point at which you want to arrive. Let the how work itself out one step at a time and don’t sacrifice your “what” for a method that leads you astray.
Can I be a helpful ear as as you try to work out your vision? Don’t hesitate to send me an email by clicking this link!
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Do You Have Dreams, Or Do You Have Vision?
January 27, 2012 by Jeremy · Leave a Comment
I have a hard time accepting things as they are. I’m more of a “how they should be” kind of guy. I’d rather vacation in Iraq, Yemen or Libya than Paris, London or Tokyo. I see discrepancies and obsess over them. My team says I’m “persnickety”—I prefer to think of myself as “particular” or “exacting.” To-may-to, to-mah-to.
In any case, I operate daily according to a vision of the future that is not yet reality.
I prefer the word “vision” to the word “dream” because dreams are so often associated with “dreaming”, “dreamy” and “dreamers.” “Dream” has connotations of other-worldliness. Apart from Martin Luther King’s wonderful speech, most “I have a dream” talk that I’ve encountered reeks of non-action, an assumption that dreaming alone is enough to spark the desired change.
Think of the spate of status updates and tweets on New Year’s Eve in which people dreamed (and invoked Dreaming’s close cousins, “Hope” and “Wish”) for world peace, an eradication of poverty, and global sing-alongs. At the risk of sounding cynical, much of our dreaming is just socially conscious enough to sound engaged and just vague enough to require zero effort of our own.
Therefore, I prefer to have vision over dreams. In the way I use the word, vision requires much of me. I work on vision. I plan for vision. I submit my vision to the critique of others so that it will be refined and strengthened. I seek partnerships to bring the vision into reality. And I pray while waiting for the correct timing to pursue vision.
This post marks the launch of a series on vision – how to define it, nurture it, pursue it and succeed in it. Ultimately I want to encourage others out there who have a hard time accepting things as they are. I want to ignite more passion in the hearts of those of you who insist on returning things to how they should be.
In the process, you will get a clearer picture of what it has required for us to get to this point as an organization. I will be honest about our failures and I will paint a picture of a future Iraq—and a future world—that I hope you will find compelling and inspiring.
We are not just out here in Iraq cranking out heart surgeries. There is a much more sweeping vision, and I feel I’ve failed to bring that to the fore regularly enough.
As you read, if there is anything you feel you’d like to ask or any way in which I might spur you on in your vision, don’t hesitate to send me an email by clicking this link.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Baroof’s Scar Stands Against Kurdish Terror and Turkish Oppression
July 4, 2010 by Jeremy · 1 Comment
The photo above tells the story of an extremely different child than the one we met in March right before boarding a plane to Istanbul, Turkey. Three months ago Baroof received a rare and complicated surgery for his age – a surgery that ultimately has spared his life and ushered in a new season of joy and obvious strength.
But basking in this season of salvation isn’t quite as easy as it might be for other children in other places. Baroof’s family lives on the Iraq – Turkey border, where for years Kurdish separatist rebels (members of the Kurdish Worker’s Party or the PKK) have been mounting attacks against the Turkish government in pursuit of an independent Kurdish nation. In response to the PKK’s terrorizing of Turkish civilians and military personnel, the Turkish government often responds with a blunted hammer where a precision tool might have been more effective.
The activities of the PKK claim to be a response to Turkish oppression. And Turkish heavy-handedness claims to be a response to Kurdish terrorism. And thus, the cycle continues.
Because of this cycle, Baroof and his family have grown up with a relatively monochromatic view of Turks and Turkey – such as “Turks are the oppressors who kill our Kurdish cousins in Turkey and cross international borders into Iraq to kill our family here as well” or something similar.
In March, we helped throw a splash of color on that single story. What was once a black and white issue has been somewhat mitigated by the kind actions of Turkish doctors who give generously of themselves and their skills to serve children like Baroof. The kindness was not lost on Baroof or his family. Now back in Iraq after surgery, they express their gratitude to Kurds around them for the Turks who saved their son’s life, thereby pushing back a single story about Turkish oppression and easy justifications of Kurdish rebellion.
Some of Baroof’s tribal members and distant cousins have died at the hands of the Turkish military. Others likely bare the scars of near-misses and raids gone wrong. But Baroof’s scar is a line of love from your heart, through Istanbul, Turkey, all the way to the border of Turkey and Iraq.
Your financial gifts have enabled Turkish surgeons to write new language into the region.
Baroof starts school again in September. Because of you, his desk will not sit empty this year. Because of you, his Kurdish friends – who might otherwise be enticed into the ways of PKK terror – will constantly contend with the scar on his chest and the technicolor story it tells.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
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OUR BLOGGERS
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Matt Willingham is the PLC press secretary and writes primarily on politics, history, general updates and visual peacemaking through photography and film. |
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Cody Fisher is a PLC cofounder and writes primarily on program development and peacemaking by giving us a lens into the lives of the real people we love. |
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Jeremy Courtney is a PLC cofounder and writes primarily to emphasize our vision and values, including organizational and financial transparency. |
Preemptive Love Coalition provides lifesaving heart surgeries for Iraqi kids in pursuit of peace between communities at odds. We offer the 30,000 Iraqi children suffering from life-threatening heart defects a chance at the surgery they need to save their lives. With our world-class international surgical partners we create long-term solutions by training local Iraqi doctors and nurses so they can sustainably save lives without our help.