William Hyman: Perfect, Good, and Good Enough

October 10, 2013

Healthcare IT, Patient Safety

In healthcare technology management (or clinical engineering), there is frequently a need for a planned response to a given situation. The situation may be related directly to safety, or it could be tied to a Joint Commission or other external directive for which the safety element or even the utility might be debated. In other instances, it may be cost or efficiency related without any immediate safety implications. In any of these cases, the general response would be to gather sufficient information to inform, formulate, and implement a plan, and then track or measure the results. A common quandary is determining how much effort to invest in this process, considering what delays might ensue from too much front-end work and not enough action. Or the opposite of that—too little front-end work, resulting in ineffectual or ill-conceived action. Some issues may require a combined response of more-or-less immediate action followed by a more deliberative investigation.

In this context and through my participation in patient-safety activities, I learned the expression, “Perfect is the enemy of good,” a paraphrase of a proverb from Voltaire. The phrase is taken to mean that seeking perfection in the analysis and plan can prevent or interfere with, or just delay, achieving what might be an otherwise good result. Excessively long root-cause analyses might fall into this category. This might sound counterintuitive to more common exhortations to do one’s best, i.e., to work hard and find the optimum solution. Similarly, it might seem like a call for accepting a mediocre solution rather than seeking the superior solution. However, delays while seeking optimization can leave a situation unaddressed that really does need more immediate action.

The good over perfect idea sounded reasonable until I read, in a chess magazine of all places, what seems to be the opposite—namely that, “The good is the enemy of the best.” The meaning of that phrase is that choosing a reasonable and expedient approach (chess move) may stop you from looking for the even better and more effective approach. This idea is not limited to chess. Instead, it more generally argues that solutions arrived at too quickly, and with too little effort, may not represent the best you could do.  At worst, such solutions might not be solutions at all.

Of course, such expressions aren’t universal truths, no matter how many times they are repeated, and it is self-evident that conflicting expressions cannot both be right. Furthermore, glib expressions are almost always grievous oversimplifications of the issues we face. In some cases, they may wrongly state the issue or otherwise be misleading. I offer, “We learn from our mistakes” as a another example. We might learn from our mistakes, but usually it takes some effort. We certainly don’t always learn from mistakes as repetition demonstrates.

So given a problem, how do we decide how to proceed? One key question can be: How quickly does one need a solution? If the answer is “very quickly,” then we must settle for a reasoned if perhaps temporary solution, and then work on determining if there is a need for a better one. Here a better solution means more than just different; it has to be measurably better by the relevant criteria. If the answer to the speed question is “no rush,” then we can address the issue more slowly, investigate more thoroughly, and consider various solutions, examining their pros and cons, before implementing the option that seems most suited to the problem and the resources. Even in such a case, it won’t be known if that solution is appropriate until we monitor the results.

It is hard to argue against seeking perfection, but when we are in problem-solving mode we always—if we are meeting our responsibilities—balance the question of criticality against time and other resources. It can be helpful when doing so to understand and consider the restraints along with the pitfalls.

William Hyman, ScD, is professor emeritus of biomedical engineering at Texas A&M University. He now lives in New York where he is adjunct professor of biomedical engineering at The Cooper Union. Hyman may be contacted at w-hyman@tamu.edu.

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2 Comments on “William Hyman: Perfect, Good, and Good Enough”

  1. John Abbott Says:

    You say, “It is hard to argue against seeking perfection.” I disagree. “Perfection” is an unattainable state and continued pursuit ultimately depletes all time and money with, ultimately, only minor improvement. I am an engineer and engineers design to specification not to some lofty philosophical objective of “perfection.” Seeking perfection is actually pretty easy to argue against.

    People complain that the government spends too much money and yet they demand perfection from all that the government does. As a rule, the public is unable to relate the cost with the goal of perfection – usually because some leader somewhere has told them that perfection is achievable. It is not, it never will be and, in fact, it cannot be.

    Sometimes one has to put the brakes on seeking perfection and be satisfied that you are living within reasonable specifications. “Great” can be pretty darn good.


    • William Hyman Says:

      All generalizations are only true in general. In the patient safety domain there are a number of contexts in which having zero adverse events is probably achievable, and therefore perfection in such matters can be reached. For example, we should be able to achieve zero wrong site/wrong person surgical events. A serious, as opposed to perfunctory, time-out should work in doing so. We should be able to prevent all tubing misconnections of certain types by using incompatible connectors instead of universal connectors. Declaring that we can’t do it is an invitation to not seriously evaluate the specific situation, to not try hard enough, and to find acceptable that which is actually not acceptable.


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