Here at the Endowment, we’ve spent more than a decade thinking about ways to find and replicate evidence-based practices. We define evidence-based practices as those with at least two randomized controlled trials (RCTs) that demonstrate statistically significant results and have been replicated in a real-world setting.
We’ve focused on evidence-based practices because our goal isn’t just to underwrite as many programs and services as we can. Our goal is to stimulate as much positive, demonstrable impact as possible. But, as we often see with even the most well-intentioned of ideas, the nonprofit sector’s focus on evidence-based practice produces an unintended side effect. The evidence-based practice designation is so difficult to attain that, once organizations achieve it, they grow reluctant to innovate. Over time, they find themselves locked into outdated programming or technology or thinking. Call it a perverse disincentive, if you will.
We know, however, that all organizations must constantly adapt, or they likely won’t be operating at peak efficiency. Consider BlackBerry, the cellphone firm. BlackBerry was a market leader about a decade ago. Its leaders should have been waking up every day thinking, ‘How do we get better? How do we innovate?’ They didn’t, and Apple’s iPhone has now rendered their once-ubiquitous product irrelevant. Ultimately, its dominance led to its demise. In the private sector, there’s tremendous market pressure to innovate constantly. We don’t have this same pressure in the non-profit world. Rather, we test programs, sometimes with the rigor of an RCT, and once those trials reveal an evidence-based practice, we then insist that those programs be replicated with fidelity.
I agree with all of that thinking. Nevertheless, it creates a mindset that can leave us complacent and too “locked-in” to allow for innovation. How do we replicate proven programs with fidelity, yet still leave room for innovation?
One organization we work with, Nurse-Family Partnership (NFP), is shedding some light on that question. NFP has won well-deserved praise for using nurses to help low-income, first-time mothers, but its program model dates to the 1970s. If you happen to have a 1970 Chevy Chevelle SS parked in your garage today, you have a 450-horsepower American classic on your hands. But when you take it for a spin, your trip likely won’t be very fuel efficient or very good for the environment.
NFP recognizes the need to innovate, and is doing so in two situations. One is in South Carolina, where NFP has entered a four-year deal with the state to bring services to 4,000 low-income, first-time mothers. NFP has agreed to reduce its costs by 25 percent in the first 24 months of that 48-month project. They’re seeking more efficiencies and new techniques for expanding nurse caseloads. Importantly, we’re using a randomized control trial to make sure we haven’t compromised the effectiveness of the main NFP program. Kudos to NFP for trying that.
Secondly, we’re in discussions with NFP and Family Connects to integrate these two complementary yet freestanding evidence-based programs. Family Connects is universal and has more of a public health approach, while NFP is more intensive and targeted. Family Connects works with all mothers, starting in the labor and delivery suite when the child is born and providing up to three nurse home visits before the child is 12 weeks old. NFP works with first-time, low-income mothers, starting prenatally and extending through the first two years of the child’s life. Now, a screening tool will be used to direct the most severely challenged mothers to NFP. Research suggests those mothers are most likely to benefit from NFP’s interventions. The idea is to create, through Family Connects, this communitywide footprint for all families regardless of income and condition, while also having targeted referrals to the more intensive intervention, NFP. The goal is to maximize outcomes at the most efficient cost. NFP is picking communities and situations where they can innovate on the margins, but the model is not compromised if the experiments fail.
Many non-profit organizations might say they’d love to do that, but who is going to pay for all the research? I would argue that we funders need to keep pushing for innovation, and in appropriate cases we need to be open to financing research to foster that innovation. We need to replicate what works, but innovation is key to staying on top of new solutions for changing times. Let’s all work harder to make sure we’re balancing both sides of this critical equation.