Continuous strategic planning in health care

Continuous strategic planning is the process of continuously recalibrating organizational strategy in response to emerging constraints and opportunities. It can differ from the traditional strategic planning approach in a variety of ways.

Benefits of a continuous strategic planning approach

Organizations that have migrated to a continuous strategic planning approach report two primary benefits: it allows the organizations to remain flexible to the rapidly changing health care environment, and it instills a culture of continuous improvement and shared accountability.

Benefit 1: Greater flexibility than traditional strategic planning

Traditional strategic planning generally runs in three- or five-year cycles, which makes it difficult for organizations to quickly shift resources or recalibrate priorities in response to emerging constraints or opportunities. This “set it and forget it” approach is too reactive and hands-off to navigate today’s rapidly changing environment.

In a continuous strategic planning approach, an organization’s long-term ambitions are broken down into short-term objectives that leaders continuously review and update. Leaders, or designated environmental scanning teams, continuously monitor both the external environment and internal progress, sharing analyses and updates with the wider organization. Leaders use this information to alter any current objectives if their goalposts have changed, add new objectives if the external environment necessitates it, or remove objectives if their work is no longer high-priority or is out of touch with the external environment.

If and when a new objective is added or altered, these organizations utilize a standard decision-making process to either assign new workstreams to teams across the organization or to end or pivot an obsolete workstream with minimal disruption.

Benefit 2: Instilling a culture of continuous improvement and shared accountability

In a traditional strategic planning approach, organizations assign strategic objective workstreams to directors or managers who then create plans to meet predetermined goals and metrics. These leaders and their teams often work “heads down” for months or years, again, following the “set it and forget it” approach. When they complete one workstream, they are handed the next one and repeat the process. It is not until the next strategic planning exercise, often years later, that these leaders come together in any strategic, future-focused capacity to discuss the organization’s position within the wider environment.

Such infrequency and disparateness can lead to an organizational culture that involuntarily values and rewards individual performance over collective ownership. Teams often work in silos, becoming distanced from strategic conversations and losing sight of how their work fits with the organization’s long-term ambitions. Leaders across the organization don’t often come together to analyze changes in the operating environment or how they can jointly work together to respond to those changes. When the leadership team does gather, it’s usually to report on their individual workstreams, not to solve problems collectively.

Continuous strategic planning leads to a culture shift away from a focus on individual performance and toward shared accountability.

Under continuous strategic planning, there is constant dialogue around each teams' progress and how that work fits in with the organization's direction. Leaders come together often to recalibrate their objective workflows against changes in the operating environment and collectively respond to challenges that arise. Leaders collaborate with other teams to find solutions, building trust in the process rather than assigning blame or critiquing one another.

Other industries, such as banking and software development, began adopting a continuous strategic planning approach as far back as the early 2000s. But because of its relative stability, health care has been slower to adopt this new mindset. As a result, the industry has continued with its traditional, three- to five-year strategic plans that don’t require constant recalibration.

Today, two factors are upending the ability to plan on such a long-term basis. First, the Covid-19 pandemic has affected the health care industry in incalculable ways. Sudden shifts in priorities have forced organizations to question foundational assumptions about their strategic direction. The pandemic introduced large amounts of market disruption (such as major changes in patient preferences) in just under two years. The scientific community expects other major events—whether they are pandemics, climate disasters, or sudden market shocks—to routinely disrupt the global economy and health care landscape in the future.

The second issue is the pace of change and variety of challenges faced by health care organizations. These organizations continue to grow in complexity and scale. Moreover, they are serving populations that are aging and increasingly multimorbid. Health care organizations are also responsible for meeting more and more targets each year.

Put simply, we must accept that health care's already unsteady foundation will continually be tested into the future. The traditional approach to strategic planning won’t work. An alternative approach that is responsive, iterative, and democratized is necessary to keep health care organizations on proper footing.

Application: Continuous strategic planning using incremental “planning objectives”

In summer of 2020, after the first wave of Covid-19 had subsided in Wales, Hywel Dda’s leaders sought to develop a more flexible and agile strategic planning and prioritization model. They began by tabulating all the system's previous strategic priorities and found 458 competing, unclear, or overlapping strategic objectives that had built up, unchecked, since 2017.

Senior leaders audited these priorities to create a clearer strategic framework. The resulting framework centered on “strategic objectives” that define the system’s long-term ambitions. One level down, it housed 65 “planning objectives” meant to incrementally move the organization closer to its six strategic aims.

The six strategic objectives are purposely written as aspirations that describe the system’s long-term identity, meaning each one should still be true in a year or in a decade. Examples of the six objectives include “putting people at the heart of everything we do” and “the best health and well-being for our individuals, families, and our communities.” They are values as much as they are goals.

Bite-size planning objectives allow Hywel Dda to course-correct to reach their long-term strategic objectives

Hywel Dda’s 65 planning objectives serve the flexible means to reach their six long-term strategic objectives. Each planning objective has two clearly defined elements: timelines and ownership.

A dedicated environmental scanning team enables flexibility and routine recalibration

Hywel Dda’s executive team saw the risk in creating lofty, long-term ambitions without the organizational flexibility to change how to achieve them. With this new approach, the organization can routinely update, add, or retire any planning objective depending on changes in the environment. Essentially, this means that priorities and workstreams are expected to change over time as the leadership team and board collect new information.

To facilitate this constant recalibration, Hywel Dda assigned a group of executives and board members to serve as a designated steering group that scans the environment for new mandates or external pressures. This group crafts intelligence-based proposals for new planning objectives or changes to current ones. These proposals clarify why the new objective is a priority, and what purpose it serves in relation to the six strategic aims.

Standardized “decision cascade” instills a culture of continuous improvement and shared accountability

Hywel Dda also clarified who makes decisions over any planning objective change and how any new work is cascaded down the organization. This has led to a culture where leaders share accountability for the organization’s collective goals.

In this new formation, Hywel Dda assigns medal classifications to describe which parts of the organization have which responsibilities.

Application: Continuous strategic planning using 90-day plans

Hôpital Montfort’s strategic direction is shaped by two inputs: long-term aspirational objectives they create internally every five years, and directives and targets they receive annually from the Ontario Ministry of Health. Until recently, when Hôpital Montfort adopted a more continuous approach, its five-year planning cycle had two negative consequences. First, it limited organizational flexibility, preventing the hospital from adapting to constraints or rapidly changing market dynamics. This caused the organization to sometimes fail to deliver on its strategic objectives.

Second, it had a negative effect on the organization’s culture. Hôpital Montfort reported that the old approach was one where each leader, from middle management to divisional directors, worked in silos on their assigned strategic objectives, which led to individuals valuing their own performance over collective accountability or collaboration. There was also limited visibility into the progress that each manager and their team made on objectives, further preventing a collaborative environment to take shape.

To alleviate these problems, Hôpital Montfort introduced 90-day strategic plans for managers. This approach has improved the organization’s level of flexibility, fostered a culture of shared accountability, and made staff more open to change.

How the 90-day plan approach improves organizational flexibility

Hôpital Montfort’s 90-day plans break down long-term strategic objectives into actionable, measurable, and iterative short-term goals. Because of the short-term time frame, the plans are inherently flexible. At the end of each cycle is a recalibration forum where leaders discuss progress and reassess priorities. Leaders identify key gaps to focus on for the ensuing 90 days, incorporating changes in market dynamics or new Ministry of Health mandates into their thinking. At the end of each meeting, every manager updates their 90-day plans with a fresh set of goals and metrics to focus on.

How the 90-day plan approach instills a culture of continuous improvement and shared accountability

Every manager with a 90-day plan is encouraged to adopt a “continuous improvement” mindset. Managers are expected to meet monthly with their divisional leaders to discuss progress and identify ways to collaborate with others, in order to improve processes or remove inefficiencies. An accountability grid ensures these check-ins occur and is visible to the entire organization, creating positive peer pressure that pushes leaders to make progress. And at the 90-day forums, managers work in groups to brainstorm action steps and root-cause roadblocks for each goal where progress is stagnant.

The 90-day planning approach has also resulted in a cultural shift, from one that encouraged individual performance to one that embraces shared accountability. This starts with the senior-most leaders. Each 90-day forum begins with the CEO, followed by other C-suite officers, divisional and team leaders, and then middle managers, each reviewing their own 90-day progress and asking for help where they need it. In response, all attendees collaborate to find solutions that help each other overcome roadblocks. And again, all managers can use the LEM system to see how others are progressing against their goals. Managers are emboldened to ask for help from peers who are progressing.

Initially, this culture shift was hard because staff hadn’t before had to grant organization-wide visibility into their work, nor had they operated under a shared accountability environment such as this. As a result, some staff left the organization. But the changes have since helped Hôpital Montfort recruit new leaders with growth mindsets and instilled a philosophy of continuous improvement throughout the organization. Those long-term gains have been worth the shorter-term pains that the migration to this approach caused.

Continuous strategic planning is a new concept in health care. Organizations can migrate to a continuous strategic planning approach in a variety of ways, but the pace of migration is dictated by what an organization’s culture and environment allow. Executives looking to pursue this approach must be willing to challenge incumbent processes and redesign the way their organization sets, designs, and delivers upon strategy.

Leaders should assess their organization’s cultural readiness before adopting continuous strategic planning processes. An organization might benefit from continuous strategic planning if:

• It has an overwhelming number of strategic priorities or objectives that sometimes overlap or compete directly with one another.
• It suffers from a lack of efficiency or flexibility caused by its current strategic planning/prioritization process.
• It has a clear strategic vision but struggles to lay out the iterative plans to make it a reality.
• It does not transparently track progress against its strategic objectives.
• It has a culture that values individual performance over collective accountability and collaboration.

As health care increases in complexity and organizations emerge from responding to the Covid-19 pandemic, many organizations are rethinking their strategic and operational planning processes. We’ll be watching out for:

1. Alternative solutions to traditional strategic planning: New strategic planning models that offer organizations flexibility and agility, allowing them to achieve their long-term strategic objectives while pivoting in the process.
2. New accountability tools: Additional mechanisms or resources that incentivize or reward staff for adopting continuous planning processes or a continuous improvement mindset.
3. Innovative goal-monitoring solutions: Processes or systems that help organizations transparently track progress against strategic objectives and promote accountability.

Continuous strategic planning offers a truly flexible means for organizations to navigate future challenges and achieve their long-term aspirations. It brings a cultural shift that increases collaboration and accountability—vital ingredients for any major strategic shift to be successful.