Even with any amount of planning, often it's better to just jump right in.

In the last post I introduced the idea of our “away month” and how it grew from a simple conversation over drinks to relocating much of our team to Brazil for a month. Here I’m going to talk more about what we’ve done to plan and execute a successful away month.

(It should be noted that it’s currently only week three out of five, so take everything here with a grain of salt. If this idea crashes and burns somehow, I’ll be sure to write a retrospective about what went wrong and why we should have known this was a terrible idea from the start.)

Here were some of the guiding principles we followed while planning the away month.

Delegation of Trust and Responsibility

In his book “The Four Hour Work Week”, author Tim Ferriss talks a lot about working from home. One of the points he makes again and again is that when trying to justify to your boss/team that you should be allowed to work from home you should be so obviously over-productive that it would be impossible for them to complain. In a way, this whole experiment is like one big period of “working from home” for the six of us currently here. Everyone knows that we’ve been given a lot of trust and a special opportunity to prove that we can be productive despite being geographically separated and in an environment where it would be easy to slack off. The handing over of trust creates an intrinsic motivation among us here to prove that we deserved it, and because of this, our productivity has remained high thus far – possibly even above average. It also helps that the evaluation of the month and possibility of continuing the tradition next year hinges on us getting some awesome work done.

Along with trust comes the delegation of responsibility to the right people. The people who were most vocal about leading the away month were also tasked with making sure it works out. This puts the incentive to make sure things are successful in the hands of those people most able to make it happen (even if they’re not necessarily “in charge”).

Taking Advantage of Local Context

Poolside brown bag talks are one of the best ways to take advantage of our local context.

Being an organization that does a lot of international work, we’re using being in São Paulo as an excuse to reach out to Brazilian organizations that we may be able to collaborate with and as a jumping off point to do more work in Latin America. It’s possible that nothing will come out of it, but if anything does it will be great to remember how our new projects came out of this trip.

This principle also manifests itself in more fun ways. Many of the team is using the trip as an excuse to learn rudimentary Portuguese. Weekend beach trips, poolside brown-bag lunch talks, and eating insane amounts of grilled meats are also a plus.

Experimentation

Despite the fact that most of us already work out of the same office every day, being in Brazil makes the work day seem different, somehow. We’ve taken advantage of this by trying out new things that we wouldn’t do in Boston. Probably the best example of this was a “field day” last Friday, where everyone on the team was only allowed to work on bugfixes or features specifically requested by our field staff (no client deliverables allowed). The result was a great day of productivity and camaraderie where many long-standing requests from the field got done and everyone felt that they were really productive. It went so well that we plan on making it a regular tradition moving forward.

These things are pretty simple, and came about organically as we brainstormed what the month would be like. Thus far it’s been a great way for members of the team to continue to do their jobs, but flipped to a new perspective. Moving to Brazil and expecting nothing to change would have been totally unrealistic. That said, allowing things to change for the better – and in a way that fit the feel of the trip – turned out to be a much better plan.

You can track Dimagi’s away month on our posterous. We’ll be continuing to blog in short and long form throughout the month.

Several Dimagi team members were awarded the Best Poster Prize at the National Conference on Medical Informatics at AIIMS February 3 -5, 2012 in New Delhi, India for their poster titled: “Performance Metrics Indicative of Supervision: A Study of Community Health Workers”.

The winning poster is available here.

The purpose of the National Conference on Medical Informatics is to explore and map the opportunities and challenges facing the growing health informatics sector. The conference explores and examines the role of information and communication technologies in reshaping the healthcare industry, proving healthcare delivery, reducing clinical risks and modernizing healthcare facilities. More information about this conference here.

The Idea Index serves as a tool to educate, network, and help solve problems. It represents a fully searchable database of socially-responsible initiatives, in all stages of development, in need of further funding and support.

More about the Buckminster Fuller Challenge here.

Krishna presented CommCare as well as spoke on a panel alongside presenters from the University of Oslo (DHIS) and the Unique Identification Authority of India.  The conference was for people with working experience of setting up, maintaining and supporting DHIS2, with the aim of preparing national teams, and also state and district level teams, of technical supporters and implementers. A broader aim was to create a resource pool of trained people for the South Asian region. More conference information here: http://hispindia.org/images/stories/nationalworkshopflyer.pdf

It was, like many good ideas, hatched out of the minds of a small group of people over a few rounds of drinks. It was in Boston, sometime in January or February of 2011, during a particularly bad winter. We stared out the windows of the pub looking through the falling sleet, and someone lightheartedly said something extremely simple:

“Winters in Boston are terrible – why don’t we just move the whole company somewhere warm and awesome for a month next year?”

Everyone laughed. We discussed the places we’d each choose to go and enjoyed the rest of the night together. At the end of the night everyone went home, thinking no more than it was a fun night out with coworkers.

But the thought lingered. Why didn’t we move the company for a month? The idea seems so ludicrous to even warrant consideration, which was why it was quickly dismissed by everyone. But actually justifying why it was such a bad idea was much more difficult. There wasn’t a good reason not to move the company.

Of course, Dimagi is a unique work environment. Here are some of the things we had going for us:

• We’re a software shop. This means that for most of us all our work requires is a laptop and an internet connection. Face to face collaboration helps a lot, but if we’re together we’re efficient, wherever that may be.
• The majority of our work is already international. This means that people are used to traveling and used to collaborating with people who are on the road. It also means we tend to attract the type of people who are open to picking up and moving their lives for a month.
• Related to that, we’re pretty young. Most of the company isn’t married and none of the devs have children yet. Doing this with a couple rug rats running around would probably be pretty tough.
• We thrive on a culture of trust and responsibility. We trust everyone to work hard without intensive oversight or clocking in.
• Finally, we like each other. This one is probably the most important. When you’re considering spending the majority of your time with people you work with you better be sure that you’re going to get along.

Even given all this, there were plenty of things for management (including myself) to be concerned about with this plan. Would the output of the team drop in the face of the temptation of fun in a foreign land? Would the separation between those that left and those that stayed make working together more difficult? Would spending too much time together cause us to all want to tear each other’s heads off? These were just some of the problems to worry about.

As we thought through these concerns and planned mitigation strategies around them, we realized that the upside of what we were calling the “away month” was just too big to ignore. The impact this could have on our culture and our sense of team was tremendous. As one of our devs put it: “I just want Dimagi to continue a place where every time I tell anyone about my job they get insanely jealous”.

So it is with great pleasure and excitement that I type these words from a third-floor apartment overlooking the Sao Paolo skyline, a place now affectionately known as Dimagi Brazil. We are just over a week into our 5 and a half week stay here and so far things are going great. We’ve started a Posterous blog that we’re using to share photos and experiences with the rest of the team and world. We’ll also try to continue blogging about our experiences, and the success (or possible total failure) of our “away month” experiment. In one of the next posts I’ll outline some of the guidelines and goals we setup to help make the month as successful as possible.

If everything goes well we’ll continue to do this every year until people no longer want to go.

For the last several years, I’ve worked around Christmas and New Years trying to write up interesting thoughts and revelations from the past and looking to the future for the Dimagi team. With the exception of 2007, I haven’t successfully sent the letter out because what I write always ends up being too trite. I abandoned this one too after I wrote it yesterday, but Cory Zue, our CTO, helped edit it for me and convinced me to send it out. Cory asked me whether I knew I was going to write about this topic or if it just came out. It was a little bit of both.  As all of you know our bottom lines:

“We care about impact, team satisfaction, and profit, in that order.”

Trying to maintain alignment between impact and team satisfaction is basically the only thing that keeps me up at night—I think profit will naturally happen if we nail the first two.
As we’ve grown significantly this year—in terms of our staff, footprint, and aspirations—we have continually had to examine what is the best optimization of our goals. We are poised for an amazing 2012, and ahead of us we have new decisions our organization hasn’t had the trouble or luxury of making before. Do we ramp up our field staff in India further? (maybe) Do we hire a dedicated sales staff? (no) How do we grow our support capabilities? How do we keep growing our impact, team satisfaction, and profit in the long term and short term?

A big part of the answer is ensuring we have the right motivation. Dimagi’s culture—which many of us think is our strongest asset—depends on a strong intrinsic motivation as an organization and as individuals. Whether it is because of travel, working on software that impacts global health, working on code that you can see affects users with your own eyes, or any other number of reasons, we assume each of us has a very high intrinsic motivation to perform our jobs. As an organization, we operate in an industry that doesn’t have an efficient market mechanism to pay for value. Therefore, we are left to determine how much value we are creating through mechanisms other than revenue or profit and loss. I’ve come to break down motivation into three buckets, and striking the right balance between these I believe will allow us to find the right balance between among impact, team satisfaction, and profit.

• Intrinsic Motivation – Things we want to do. Whether it’s coding, implementing, selling, writing, e-mailing, or attempting to write annual letters, we do it because we want to. Because we want to, because we are all pretty smart, and because we are hard-working, we tend to get good at these things.
• Mixed Motivation – Things we want to want to do. These either used to fall in to the Intrinsic Motivation category but just don’t quite get us out of bed anymore, or, we think we see the value of doing them but there is something nagging in the back of our mind that it is just not actually valuable.
• Extrinsic Motivation – Things that we do because we have to. These are things we don’t think we should be doing but are doing it just because someone (a client, a manager) is making us.

At any time, all three of these motivations are driving parts of our behavior. Tasks that used to be easy may now fall into the mixed or extrinsic category. I would guess tasks actually cycle between these much more than we realize. I used to be concerned that everything we ask ourselves to do falls into the intrinsic motivation bucket or we risked diluting our culture. However, I think that concern was misguided. Certainly, if not enough of a person’s job is intrinsically motivated it will show and they will quit or be fired. But not everyone will be intrinsically motivated to accomplish everything on their plate at any one time. What matters is the support, communication, and transparency to knowingly allow individual tasks to fluidly move between these categories while still maintaining an overall high-level of intrinsic motivation for one’s job.

I think this is the key to what Malcom Gladwell and others have recently coined as “deliberate practice” among the high-performing individuals in sport, arts, music, entertainment, and other areas. They are the best at performing because they are the best at practicing. But that’s fairly obvious after you hear it. The question is how to find the motivation to be good at practicing. For me, part of it comes down to understanding what is driving myself and mentally maintaining that drive. As Neal Lesh, our CSO, and I discussed, sometimes you either have to do something or want to do something before you go to bed. What separates highly productive organizations and people is whether you think you have to do it or want to do it. What lets highly productive people sustain those levels is that they have to do it because of intrinsic motivation. Further, they accurately separate the list in to the right piles “have to” and “want to” to maintain the best motivation.

So, this will be the challenge for ourselves and our organization in 2012. How do we continue to grow in size and impact while maintaining a high -level of intrinsic motivation and a culture of “deliberate practice.”? It takes a significant—and sometimes uncomfortable—amount of effort and self-reflection as individuals and as an organization to determine what is driving us, what we wish was driving us, and whether we care enough to do anything about it. And it takes even more effort to actually do something about it.

Earlier this year, we began piloting ADM internally and externally with our CommCare projects to validate its value proposition, adjust our current approach, and receive feedback from on-the-ground project managers. Internally, we found that ADM drastically increased our own knowledge and awareness about the performance of our partners’ projects and successfully raised pressing issues for follow-up by our internal staff. Externally, we tested our report prototypes with our partner project managers.  They found ADM extremely valuable in its ability to both shine light on their project’s weak performing areas and establish clear ways to address them.

Due to the success with ADM’s application with our CommCare-based projects, we extended this approach to our other projects. We have a number of partners operating in the SMS/Logistics space where the principles of ADM can apply equally. Shortly after ADM’s introduction in these projects, our Dimagi program manager noticed a significant increase in the reporting rates of some projects. In one case, there was a 30% improvement in reporting rate over a 4 week period.

This example highlights the tremendous benefit and possibility for workforce performance improvement through ADM’s approach. Routine follow-up action based on operational insight is the most powerful agent for enhanced program performance and, subsequently, impact.

We’re now ramping up this effort with several of our partners building ADM in their project plans.

For more information about CommCare, please visit www.CommCareHQ.org.

This award will help Dimagi advance its Active Data Management (ADM) initiative. We will fund the Maternal Concept Lab (MCL) to harmonize data elements across several CommCare applications and the CORE Group to coordinate the international NGO community through its 60 members and associates that reach over 720 million people every year. With input from the larger community, we will create and develop common cross-cutting benchmarking and ADM reports for maternal and child health applications.

The award will last two years until the end of 2013.  During this time, the eight grantees will meet regularly to share lessons learns and hopefully to identify areas for potential collaboration.

The Norwegian government’s press release is available here.

Rekha, an ASHA from our pilot site in Rajasthan, called me tonight. “I missed you and wanted to talk. When are you coming back to Kishangarh, sister?” she asked. I felt a warm and fuzzy feeling inside. It’s quite endearing to get calls from the ASHAs.

Will the novelty wear off with time?

We spoke about progress in her village, both with and without CommCare. She had only good news to share. She said women love the information they can see and hear in the program and aren’t bored by it. They pay attention and ask questions.

For the past few months, Rekha’s had the highest number of form submissions of the pregnancy checklist. This is a multimedia-enabled mobile form, which asks questions about antenatal care check-ups, tetanus immunizations, contains reminders for the women to take their iron pills daily. The form also disseminates information (both through audio and visuals) about dangers signs a woman can experience at different stages of pregnancy, encourages the woman and her family to prepare for cost and transportation in advance, in case of an emergency. New information is displayed based on the stage of pregnancy. It changes about every 3 months or so.

In addition to highest form submissions and she also is one of the ASHAs with high case activity percentages, which means she’s covering 100% of client base very often. When I spoke to her three months ago, she said that she circulates the pregnancy checklist and shows the information in her mobile phone to the pregnant woman in her village every two weeks!

So I asked, “Are the women getting bored? They see the same information over and over. Is it not a novel tool anymore?”

Her answer was simple, “No, they still come and listen and watch. But they do ask, ‘Does she [woman in the mobile] always say the same stuff?’ ‘Yes’, was her answer. And that was it.

More immunizations for both women and children

All of the ASHAs say there’s benefit in using CommCare and that they’ve experienced some kind of kind. I tried to get her to quantify the change. She said, all of the children in her village are coming out for immunization now. Before she used CommCare, at least 50% would be missing.

She also said more women are getting their tetanus immunizations completed than before. On Immunization day, one or two women would be missing.

Please let me step back for a bit. What I’ve learned is woman will happily (if they feel pressured enough) get immunized themselves for tetanus while they’re pregnant, but they resist bringing their children for immunizations. Typical reasons are my baby will cry, it will hurt my baby, it results in swelling and pain for the baby.

The application that Rekha is using only has an antenatal application, and not a newborn module, which would contain information on children’s immunizations. Perhaps the cycling of the information to the women of her small community has resulted in greater uptake of immunizations for children? As I mentioned earlier, the pregnancy checklist contains information about the importance of getting tetanus immunizations for the woman. I’m not sure, but I’d like to believe it. Naturally an informed and aware woman will understand what’s necessary for the health of her baby, isn’t it?

ASHA adapts CommCare in an unexpected way!

Rekha’s also doing something very innovative with the multimedia stored in her phone. It blew me away when she first told me. After two months of using CommCare, one day during Immunization Day in her village, Rekha decided to play the audio files through the media player for small groups of women who were waiting to get immunizations for themselves or their children.

The audio played without pause actually sounds like a conversation between two women about antenatal care topics. The way we named the files results in the following playlist: 1) a woman says, she does not know about topic xyz; 2) a health worker gives information about this topic; 3) a woman says, yes, she knows about topic xyz. And this flow repeats for 45 antenatal topics!

A couple women came up later to ask the ASHA more questions about topics raised in the “radio show”. According to another ASHA in our pilot, the audio-visual information available on CommCare is similar to the way information about health is shown on television or heard on the radio. Not only is it an interesting and engaging medium, but a convincing medium for villagers, who believe and trust information from media sources like TV or radio (more-so sometimes that what their ASHAs tell them).

[Only recently, after my work in Bihar, did I realize why this is. Some people in villages are skeptical of the information the ASHA gives about having an institutional delivery, going to the hospital to get antenatal care checkups completed, or opting for sterilization as a method of permanent family planning because they know ASHAs get incentives for all of that work. They believe the ASHA works for the money and not for the people. (I will write another post about on this issue at a later date)]

One woman’s story

Three months ago, I felt especially connected of a story Rekha told me of one woman in her village. This woman’s husband is an alcoholic and forbids her from going to the Anganwadi center, or speaking to the ASHA. This woman heard about ‘the program Rekha was given in her mobile phone for pregnant woman’ through word of mouth. This could happen when women go to fetch water, or walking to the fields. This woman snuck away from the home without her husband knowing to the Anganwadi center on several occasions to learn the information and benefit from the program. She had heard there’s information about pregnant woman that Rekha has to share, and she also felt like she should hear it!

My first takeaway: A novel tool can attract people and want to access information through it.

I asked about this woman today. Rekha said, she came to learn the information from CommCare (which was a big step on its own), but never took up the practices as they was forbidden by her husband. This woman was the only woman in her village, who experienced complications during pregnancy, was transferred to Ajmer for emergency care and lost lots of blood there. Her newborn died within 4 days. She’s recovered now.

Rekha said, the main problem was the husband hadn’t arranged for transport in advance, didn’t allow her to take the pills, let her get looked at by an ANM (auxiliary nurse midwife) or get immunized. I wonder what he’ll decide to allow/disallow for their next pregnancy after being the only family that did not follow the practices encouraged in the application.

My second takeaway: People learn from real stories and do what other people do right.

I wonder if Rekha will cite this example as a behaviour change weapon along with CommCare. Rekha was among the top performers for form completions and case activity rates. Every single pregnant woman who saw CommCare in the past 6 months had a healthy pregnancy and are now breastfeeding, except one (she’s only had an about 7-8 pregnant woman in the past 6 months). By way of example of that one woman’s story, I wonder how people’s opinions have formed for the information in CommCare and the credibility of the ASHA. Through CommCare, ASHAs are able to share information, comprehensively, correctly and with credibility. Now, let’s hope it can motivate service uptake and break down barriers.

On that note, I think there’s so much value in filling out the counseling type forms within the home, where there is a higher probability of a (resistant) family member being present and at the very least half-listening.

My third takeaway: Encourage ASHAs to complete all counseling forms at the home, instead of at the Anganwadi Center, where household decision makers may also tune in and learn.

Check out Rekha in action on YouTube. Courtesy Daniel Pepper.

YouTube: Rekha