In this article, we tackle the topic of Healthcare Strategy Deployment, also commonly referred to as Policy Deployment, Management by Planning, and Hoshin Kanri. Strategic deployment, what we refer to as directional alignment, is the process of cascading the organizations strategic direction through the different layers within the organization so that the proper tactics and actions can be developed and aligned. In our previous post, we discussed good system design in healthcare which is primarily focusing on the patient experience, i.e. creating alignment along the “horizontal.” Now we will focus on how to expand upon that alignment along the vertical using Directional Alignment.
Sometimes we come to realize the why for a solution when-and-only-when we begin to implement the solution. This was the case for a healthcare client of ours. Upon the completion of strategic development, it became immediately evident that there were many activities in motion that didn’t align with the direction, and that had to be stopped. There was also a significant number of critical activities missing that needed to be catalyzed.
For example, the Epic systems team was designing IT enhancements for two separate groups, e.g. physicians and nurses, that contradicted each other and that did not support the strategy for the medicine patient service line. Furthermore, several executive committees were in place to help achieve flow, another key strategy, but activities being done by these committees did not align with problem solving by the frontline managers. In absence of Directional Alignment, we had a large number of people working hard on different “stuff,” but not all of it aligned to the strategic direction for the organization. In other words, the activities that employees were spending their time on was a major waste of resources. Furthermore, we realized there were no activities in place around training nurses to deal with behavioral health patients, a key strategic service line that was growing. If any of this sounds familiar, you are not alone. Unfortunately, the consequences of such fragmentation are felt by the patient:
Patients regularly encounter fragmented systems of care and the results often lead to unmet social needs, conflicting medications, incorrect dosages etc.1
Strategy exists to 1) create an ambitious direction, 2) create alignment, i.e. limited resources and time, towards achieving that common direction, and, most importantly, 3) coach and develop people to grow so they are continuously able to solve complex obstacles. In doing so, healthcare leaders demonstrate respect to their employees by ensuring their time and efforts will be dedicated towards that which matters and to their patients by ensuring the issue of patient care is tackled in a focused manner.
Hoshin Kanri, the term used by the lean community for strategy, models the PDSA (Plan Do Study Act) method. The planning begins at the executive level with strategic planning. Strategic planning typically involves scanning the competitive landscape and creating three to five-year breakthrough strategies that will provide an edge. Once this is done, objectives centered around the IHI Triple Aim are established to achieve the strategic plan and are typically broken down into 1-2 year objectives to create short-term focus.
At this point in strategy deployment, a communication process known as “catch-ball” is initiated.
Executives cascade the strategic breakthroughs and objectives to service line managers. In reaction, these managers will take the strategic breakthroughs and provide more detail on the how, i.e. the planning continues. One way of doing so is through the use of value stream mapping with a focus on patient experience as we discussed in the last blog. Value stream metrics and targets are established that tie back to the executive objectives and a future state value stream map demonstrates how the work will be done at the hand-off level to meet those targets and to provide the best patient experience. This how is then shared with the executives who get a chance to provide their feedback and ensure the plan aligns with the direction. Once this is done, the plan is “locked in.”
The future state map should also be used to play catch-ball horizontally, providing direction to the functional support managers on what to focus their efforts on. For example, rather than having IT work on fragmented requests made by individuals in the organization, in this scenario, IT focuses on work that bridges the gap from the current state value stream map to the future state value stream map.
The catch-ball process continues from the service line manager to the unit manager level. At this point in time, action plans are developed that are more tactical. These action plans get cascaded down to the supervisor level and execution of projects begin.
There is an important shift happening in the broader Lean community that is also starting to take place in healthcare. Toyota Kata, a book and method developed by Mike Rother, sets the groundwork for moving from project plan thinking to true PDSA thinking. For the last 10 years our team has been further developing, elaborating, and deploying Kata. Within the Kata model, there are a few key points that enhance Strategy: 1) create a target condition and experiment quickly and 2) Be a coach, have a coach.
Proper strategy is composed of ambitious, breakthrough goals. Rother refers to this as something beyond our knowledge threshold. In traditional strategic development, project plans are concrete plans set in stone that march towards the danger zone (see image below).
However, with the Kata approach, rather than develop a project plan, we create a target condition to be achieved in a shorter time frame (as short as 1 week when first practicing the Kata approach) that connects back to the challenge (a theme that connects strategy with process level execution and is typically one to three years out) created at the service line level, typically a future state value stream map. A target condition enables fast experimentation, i.e. the mindset of fail fast. In our example above, the service line manager would share the future state value stream as the direction, and the various unit managers would then set unit target conditions to iterate towards that direction. In turn, the unit managers would share those unit target conditions with their supervisors, who would create process target conditions in response. At this point, they would iterate towards those target conditions through using thoughtfully developed yet quick experiments to overcome obstacles. This is where the knowledge threshold is breached, learning happens, and obstacles are eliminated.
In this model, it is also important to note that the service line manager serves as a coach to the unit manager, i.e. the learner. In turn, the unit managers serve as a coach to the supervisor, i.e. the learner. Thus, everyone should be a coach and have a coach.
In healthcare, this shift has a positive impact. As pointed out in an article, Report: Fundamentals of Healthcare Will Change by 2020 and in our blog, Lean: The Hidden Method to Achieving Success in Value-Based Care, the landscape of healthcare is changing rapidly. Project plans intended to deliver value over the span of a year may be delivering the wrong value when all is said and done. Thus, aligning resources towards an ambitious direction and allowing them to iterate quickly is the key.
Here at W3, we’re at the forefront of this shift in the way Strategy should be developed and deployed.