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Strategic Planning as PartnershipBuilding:
Engaging the Voice of the Community
Anthony L. Suchman, MD
Penny R. Williamson, ScD
Diane B. Robbins, MA
John C. J. Cronin, MA
Author affiliations:
Relationship Centered Health Care and the University of Rochester (ALS)
JohnsHopkinsUniversitySchool of Medicine (PRW)
DB Robbins Consulting, Seattle, WA (DBR)
Northern Berkshire Health Systems, North Adams, MA (JCJC)
Corresponding author contact information:
Anthony L. Suchman, M.D.
Relationship Centered Health Care
42 Audubon St.
Rochester, NY14610
phone: 716-271-4233
email:
Copyright 2001, Anthony L. Suchman, Penny R. Williamson, Diane B. Robbins, John C.J. Cronin
I
A new perspective on strategic planning
Strategic planning is the process by which an organization establishes specific goals and priorities for pursuing its mission in the context of its current and anticipated environment. Typically strategic planning is an activity of senior managers, drawing on market share, financial and operations data and a broad environmental assessment (including predictions about competitors, new technology, the local population, the economy and changes in reimbursement and regulation). The product of this effort is a detailed multi-year work plan, complete with specific measurable targets; it is this tangible output – the strategic plan – that is usually seen as the main reason for engaging in all this activity, the principal source of its value.
Unfortunately, the realities of the world often confound the ideal of strategic planning. No sooner is the plan finished than unanticipated developments render much of the original blueprint irrelevant. People in the organization keep on doing what they have always been doing without much knowledge of or regard for plan’s contents. The new performance indicators don’t get created, or if they do, they’re not given much attention. As often as not, the strategic plan ends up sitting on a shelf gathering dust.
Not only does the plan turn out to have little impact, but also the process by which the plan is created may be counterproductive. It may perpetuate outmoded roles and mindsets that undermine the very changes the organization is attempting to make. For example, having a small group of senior leaders develop the plan on behalf of the entire organization reinforces a pattern of paternalistic hierarchy even as the organization is attempting to foster greater participation and partnership. The emphasis on quantitative information (“hard data”) reinforces detached observation and objectification even in the face of efforts to become more sensitive to the subjective, lived experience of both patients/customers and staff.
We propose an alternative view of strategic planning – that its value is as much in the process of creating the plan as in the ultimate content. We suggest that strategic planning offers an ideal context for holding an extensive, in-depth conversation across stakeholder groups. The shared vision (a general plan), mutual understanding and enhanced relationships that emerge from this process will be more robust resources for the organization – applicable across a wider range of business environments and less susceptible to obsolescence – than the contents of an overly detailed quantitative plan.
A methodology of participation: Appreciative Inquiry
A change in perspective on strategic planning requires a modification of methods. While formal analyses of market dynamics, financial performance and operations continue to be essential, they are not sufficient. Something else is needed to bring in the perspective of human stories, qualitative data about the lived experience of working with or in the organization. Appreciative Inquiry (AI) is a methodology for organizational change – for planning, improvement, and relationship building – that is ideally suited to a participative, relationship-oriented approach to strategic planning. (1-3) AI leads individuals and organizations to imagine, design, and enact a visionary future through reflection on the best of their past experience (see Table). It integrates the ancient human tradition of weaving community through storytelling with modern theories about the social construction of reality through conversation. (4;5) It is particularly effective for fostering dialogue and integrating perspectives across differences, and for aligning the motivation and aspirations of individuals with the trajectory and needs of the organization.
II
A case study
To illustrate this new perspective on strategic planning – to bring it to life – we turn now to a case study of a strategic planning process in a newly-formed integrated health system. This process successfully combined Appreciative Inquiry, scenario-based planning (6) and the other more traditional elements of strategic planning.
The setting
For the past 4 years, Northern Berkshire Health Systems in northwestern Massachusetts has been reshaping itself to move beyond the provision of “sick-care” to adopt a population-based approach to improving the health of the entire community in its geographic area. This initiative included the vertical integration of existing healthcare institutions including an acute care hospital, a homecare agency and its hospices, and a local skilled nursing facility and retirement community to form NBHS. A community health foundation was also formed to access philanthropy to support community health initiatives not financed by the health care payment system.
As NBHS prepared for its first cycle of strategic planning as an integrated system, it sought to strengthen its relationship with its community by bringing the community directly into the planning process as a full partner. Rather than asking managers, healthcare professionals and board members to be proxies for the community in determining its needs, this new process was intended to allow the community to speak for itself regarding its goals, values and hopes for local healthcare. Thus the project might draw on the collective wisdom of the organization and its community, thereby enhancing the likelihood that the resulting plan would match the community’s needs, enjoy broad community support, and be sustainable.
The planning process was also designed to promote dialogue and strengthen relationships between the various stakeholder groups – those in the community as well as those within the system, and to reduce the insularity that can be characteristic of governing boards. (This insularity had emerged as a concern during a governance retreat held a few months earlier.)
The strategic planning process integrated five components: the community interviews, an analysis of market and utilization trends, an analysis of key clinical programs, a facilities plan and a scenario-based assessment of NBHS’s future environment. In almost every component of the process, we made extensive use of individual interviews, small group dialogue and personal reflection to bring forth the voice of each participant and to foster the creative synthesis of diverse viewpoints. We will first give a detailed account of the community interviews, and then describe how the five components were woven together.
Community interviews
The purpose of the community interviews was to gather and learn from stories of successful experiences within the organization in order to identify its core life-giving factors, to create a dream for the future, and to design the organization in a way that would be congruent with that dream. To ensure diverse input, members of 12 major stakeholder groups (hospital patients, senior living center residents, public service agencies, religious groups, local businesses, insurers, NBHS employees, members of the NBHS governance structure, consumer advocates, physicians, nurses, and other health care providers) were invited to participate on the Stakeholder Interviewing Team. Nineteen volunteers came to the first meeting; 18 stayed with the project to its conclusion, collectively donating over 1200 hours of their time.
The Stakeholder Interview Team met for three 2-day workshops. At the first meeting, the team was introduced to the purpose and plan for the project. Team members interviewed each other to gain familiarity with AI and to determine which themes would be most important to include in the community interviews. We developed a script for the community interviews addressing the themes identified in this first workshop.
At the second meeting, the team members learned how to conduct appreciative interviews. At first they were skeptical about AI and its focus on instances of success. They believed that if problems weren’t explored, the interviews would be superficial and ineffective. However, through their own experience they discovered that exploring interviewees’ stories of success and wishes for the organization’s future does indeed address problematic areas, but with a greater sense of possibility and hope, and less blame and defensiveness than a more traditional “tell me everything that’s wrong around here” kind of approach. Over the next month, the team members interviewed 5-10 community members each, for a total of 136 interviews, most lasting an hour or more, plus another 1-2 hours per interview for documentation.
The 18 members of the Stakeholder Interview Team met for a third time to analyze their data. Using a qualitative research strategy called narrative analysis, the team members abstracted themes from all 136 interviews using a classification scheme that they invented based on the content of the stories. (7) Going back to the stories over and over again as a reference point, the team found several overarching themes that seemed to represent the core of what is most life giving when NBHS is at its best. From these themes the interviewers created three “Compelling Images” of the future of local healthcare (summarized here and reproduced in full in Appendix 1):
1)Caring relationships based on compassion, deep listening and mutual understanding.
2)Partnering to achieve the greatest good for patients, their families, and the entire local community.
3)Full spectrum excellence, providing access to and individualized coordination of services across the spectrum – from self-care programs to locally provided professional services to specialized services at regional medical centers.
Traditional planning activities and scenario building
Even as the Stakeholder Interview process was moving forward, several other groups were undertaking studies of the type more traditionally associated with strategic planning. One group assembled data on market share, utilization rates and financial performance at NBHS. Another group reviewed the state of the existing facility and perceptions of its strengths and limitations. It prepared a report outlining options for the reconfiguration of existing services and the development of a new professional office building. A third group studied several core clinical services that had not been meeting performance expectations.
A fourth group conducted a half-day exercise in scenario building. (6) It sought to identify those characteristics of the local and national environment that would have the most impact on the health system over the next 5 years. Some of these driving forces were already known, e.g. the increasing age of the population, increasing information access, and certain new drugs and technologies. Others were unpredictable, e.g. the state of the local and national economy and the political climate. The various drivers were clustered and described in narrative form as three stories of potential futures in which NBHS might find itself (Appendix 2). One scenario involved robust local growth and the further emergence of a two-tiered health system. A second involved the collapse of private health insurance and the rise of a national health program. A third postulated the emergence of consortia of provider groups as the leaders of health care planning and delivery, driven to meet the service needs of a new breed of actively engaged patient-customers.
Putting the pieces together
Five months after the inauguration of the Stakeholder Interview process, members of all of the workgroups and the Board of Directors met for 2 days to review and integrate the information from each of the various components. In planning the retreat, we were concerned that if the Stakeholder Interviewing Team simply presented a written document to the board, the power and meaning of the stories – and the sense of deep connection with the community - would not be adequately transferred. We were also aware that each participant would be most familiar with (and therefore partial to) one kind of information. We wanted a more complete picture to emerge from the combined perspectives, which meant that we had to help people access types of data with which they were not necessarily familiar or even comfortable. A more relational and dialogic process than the mere submission of written reports would be necessary.
The retreat was designed to allow board members to develop a deep understanding of the work that was being passed on to them, to give workgroup members confidence that their work was understood and would have a meaningful influence on the strategic plan, and to give all participants a sense of the “big picture.” The retreat began with a presentation of the Compelling Images from the Stakeholder Interviews. This was done in the form of a skit – a mock living room conversation between community members. Then each of the other types of data was presented in a more traditional fashion – a front-of-the-room presentation supported by overheads. Each presentation was followed by dialogue in small groups to explore the relationship between the data just presented and the Compelling Images. Board members and workgroup participants were comingled in each of the small groups. They discovered that the stories and the quantitative data informed one another powerfully – for example, the themes of caring, partnership and excellence shed light on the likely causes of certain market share trends and suggested potential responses. The future scenarios fostered consideration of how the three Compelling Images might guide organizational strategy in the three different environments; participants were able to recognize that some initiatives would be relevant in any scenario.
The retreat culminated with a brainstorming exercise that produced 15 specific action steps, based on the Compelling Images, for the board to consider. The senior managers of NBHS subsequently consolidated these 15 steps into five initiatives; three of these were presented and approved at the very next Board meeting (see Appendix 3). As a result of the retreat, a variety of unanticipated new relationships were established – people working together who had not previously done so – that continued after the retreat was over.
During and after the retreat, many people related that their perspective had been broadened by the chance to encounter and discuss such a diverse mix of information (see Appendix 4). Qualitatively-oriented people expressed new appreciation for the power and importance of numbers; surmounting their initial skepticism, quantitatively-oriented people discovered a sense of direction, purpose and moral urgency in the community’s stories. Appendix 4 also shows that not everyone was comfortable with the format or found the retreat worthwhile, although most did.
The strategic plan, the Compelling Images and several of the stories from which they arose were presented throughout the community and received a very enthusiastic response, including favorable newspaper coverage. It was particularly symbolic and meaningful to community members that the plan was based on their own stories, and that the interviews had been conducted by their own peers rather than by outside professionals. In implementing a strategic plan based explicitly on themes voiced by the community, the Board of NBHS communicated powerfully its intention to listen deeply to its community and to work in partnership.
III
Discussion
The multi-method approach to strategic planning used by NBHS engaged and integrated many voices. The extensive stakeholder interviewing project was combined with more traditional analyses of utilization, market share, finances, clinical programs and the physical plant. Diverse elements were successfully woven together: stories and values with numbers and trend analyses. We can identify three important benefits from this process.
First, this juxtaposition of elements gave the participants a better opportunity to understand each other, and to feel understood. For those familiar with the “heart” of the community stories it provided the rigor of numbers to underscore the importance of these themes. For those familiar with the numbers, it enlarged understanding of the story behind the numbers; knowing what mattered to the community prompted new insights about how to address problematic trends that the numbers portrayed. When the Board members engaged in direct dialogue with members of each of the working teams, they had a better opportunity to understand deeply the information that was being presented to them than if they had received written reports. Likewise, the members of the working group were able to feel more confident that they had been heard and understood, and that their efforts mattered.
Second, the organization’s capacity to be creative and wise in its planning was enhanced by the greater diversity of both participants and kinds of information that were included in the strategic planning process. A wider range of themes and ideas was available to be included in the emerging coherence of meaning – analogous to a wider variety of threads allowing for greater artistry in the weaving of a tapestry. The strategic plan that emerged from the participatory process at NBHS was unlike anything the board would have created on its own. Greater diversity also reduced the possibility that important themes would be omitted.