There Are Better Practices to Best Practices

In 2008 researchers at eight hospitals around the world, from Seattle to Delhi and from Toronto to Amman, began using a nineteen item surgical safety checklist created by the World Health Organization. The list asked teams to confirm the patient's identity, the site of the operation, the availability of blood and the count of instruments. The results, published in 2009 by Atul Gawande and colleagues, showed a drop in major complications of about a third and in deaths of nearly half. It is a clear example of a best practice, a simple procedure that is better than what most people do. The topic nevertheless claims that there are better practices than best practices, and the claim deserves attention.

The idea of best practice has a long ancestry. In the early twentieth century Frederick Taylor argued that every task had one best way, which could be discovered by timing and analysis, and that managers should impose it on workers. His scientific management raised productivity in factories, and the notion spread to every field. Today the language of benchmarking, standards and templates is in every organisation, and consultants, development agencies and ministries carry the lessons of one place to another. The logic is attractive, because it saves the cost of reinventing the wheel and lets the weak learn from the strong.

For routine tasks the logic holds well. An airline pilot who follows a checklist and a nurse who washes her hands as the protocol requires are applying knowledge that others paid dearly to acquire. There is no virtue in experimenting with hand washing. For tasks where outcomes are predictable and the method well tested, best practice reduces variance and error. The surgical checklist shows that standardisation can rescue lives. The topic would be wrong if it denied this.

But the term has problems. The first is the word best. It suggests a final answer, and a practice described this way becomes a ceiling and not a floor. If everyone follows the standard, nobody looks for something better. Tom Peters and Robert Waterman published In Search of Excellence in 1982, a study of forty three firms that they considered models of good management. Within a few years several of them were in difficulty, and the practices had not saved them. The label froze a moment, and the world moved on.

The label froze a moment, and the world moved on.

The second problem is context. A practice that works in one setting may fail in another because it depended on conditions that were not copied. Finland's schools, which scored very high on international tests, were studied and imitated by many countries, but the results were often disappointing, because the success rested on a high status for teachers, a culture of trust and a small and equal society that no reform memo could transplant. Amul, the dairy cooperative of Gujarat, was a spectacular success under Verghese Kurien, yet attempts to reproduce it elsewhere have met mixed fortunes, partly because it grew from local politics and leadership.

Medicine illustrates the point from the other side. For decades doctors followed the best practice of recommending bed rest for acute back pain, until trials in the 1990s showed that staying active produced faster recovery. Hormone replacement therapy was standard advice for postmenopausal women until a large trial reported in 2002 that its risks had been underestimated. Best practice is a snapshot of current knowledge, and knowledge is revised. The practitioner who treats it as final becomes the last to learn of the revision.

Development economists have given the failure a name. Lant Pritchett and his colleagues describe isomorphic mimicry, in which governments adopt the forms of successful institutions, such as the same laws, offices and organisation charts, without the functions. A country may create a new anti corruption agency modelled on a famous one, and find that it achieves nothing because the pressures and incentives that made the original work are absent. It resembles the cargo cults of the Pacific islands, where people built runways and wooden aeroplanes in the hope of attracting the goods that had once arrived by air. The ritual was copied, and the cause was not.

What, then, are better practices? One answer is practices that are fitted to the place and the people, often found by local experimentation. Toyota, whose production system is held up as a model, does not treat its own methods as fixed. The principle of kaizen, or continuous improvement, invites every worker to suggest changes, so that the practice is always being replaced by a better one. A good practice is a hypothesis to be tested. The Indian experience with Kerala's decentralised planning in 1996, in which villages drew up their own development plans, and with the Self Employed Women's Association in Ahmedabad, built from the needs of its members, shows solutions that came from below.

A second answer is that practices should be adopted with their reasons. A team that knows why the checklist includes a certain item can adapt it when conditions change, whereas a team that follows it blindly cannot. Understanding the principle behind a practice allows one to keep what matters and to alter the rest. The surgeons who benefited from the checklist were not merely obeying. They discussed it, adjusted it to their theatres and made it their own, and the hospitals where it was imposed from above without discussion saw weaker results.

Yet the argument cannot be pushed to the point of rejecting all standards. Every better practice, once proven, becomes the next best practice, and the cycle starts again. A society that refuses to codify what it has learnt will keep repeating its errors, and an organisation that mistrusts every template will exhaust itself. The sensible position is to hold practices lightly, using them as starting points and replacing them when evidence says so. Whether this is a better practice than best practice, which can only be judged by results over time, or merely the newest best practice, no consultant has yet been able to explain, and that may be the only humble conclusion on offer.