By Terrie Kurrasch, FACHE

Despite the inclination of many hospital executives to simply make annual updates to an existing plan, successful strategic planning requires the inclusion of all stakeholders. Ratcliff recently conducted a survey of California hospital executives on the topic of health care strategic planning (click here to view results). More than half of the respondents indicated their plans were updated annually; not surprisingly, 87 percent felt their planning process was sufficient or very effective. These findings were further supported by a survey conducted in 2005 and 2006 by the Society for Healthcare Strategy and Market Development of the American Hospital Association and Health Strategies & Solutions Inc., Philadelphia. This work also found that respondents gave themselves fairly high marks for following through on the identified strategic initiatives, but thought the satisfaction of key stakeholder groups with their respective plans was low.

Can we consider the results of these two surveys representative of strategic planning jobs well done? Were the completed plans future-based and did they provide adequate guideposts to lead each organization forward? While strategic plans can be time-consuming to develop and should be among the top priorities on board agendas, the resulting plan is generally one-dimensional, created in quasi-isolation by the senior leadership team and focused largely on market forces. However, to fully comprehend the impact of these market forces, a holistic/multidisciplinary approach to the strategic planning process should be used.

A more inclusive approach
The use of a more inclusive approach to strategic planning is supported by Alan Zuckerman, FACHE, FAAHC, in the Winter 2006 edition of Frontiers of Health Services Management, a publication of the American College of Healthcare Executives (ACHE). In his article "Advancing the State of the Art in Healthcare Strategic Planning," he notes that strategic planning in hospitals is still a very top-down versus bottom-up process. Zuckerman further states, "Dominated by senior management, and to some degree, the board, planning in most organizations engenders very little participation, awareness, and ultimately support from the majority of employees, and even less from customers."

Evaluating the survey results for the use of an inclusive process to maximize the outcome, it appears that the mark may have been nicked but not hit. Many leaders may be taken out of their comfort zone when a wide variety of stakeholders is involved in a strategic planning process, but the resulting plan will certainly show the valuable impact of this process. It's a big step to take, but as David Lloyd George, a former Prime Minister of England, said, "Don't be afraid to take a big step when one is indicated. You can't cross a chasm in two small steps."

In the broadest sense, the planning team should include a wide variety of clinical and non-clinical stakeholders. Operational analysis, as appropriate, facility evaluation and facility planning implications should be key components when evaluating the strategies. This level of work can generally be completed by hospital staff with the support of a knowledgeable consultant and/or qualified architect. Use of an inclusive approach to develop a strategic plan will provide the organization with a well- grounded roadmap for the future that can be implemented with a strong degree of certainty. In the ACHE report cited above, Sutter Health's Manager for Strategic Business Development Kathryn Alexander said, "The value of strategic planning is derived from its ability to bring an organization's leaders and stakeholders together to formulate strategic direction in view of environmental uncertainties." Little did Alexander know in 2006 just how uncertain the health care environment would be today!

Zuckerman, who is president of Health Strategies & Solutions Inc., also notes that developing focused, clear strategies is one component of a state-of-the-art strategic plan. He writes, "the means must directly and forcefully address the critical issues identified, while incorporating contingency plans and recognizing likely barriers and constraints." It appears that he fully supports an integrated approach to developing a strategic plan, because information obtained from all participants will reveal the barriers and constraints early in the planning process.

If market forces and planning/facilities requirements are researched and evaluated in tandem, a health care organization will develop a comprehensive strategic plan that can also include a realistic cost estimate for its implementation relative to space requirements and equipment. A hospital's board of directors will be better prepared to weigh the pros and cons of implementing each strategy if they can include in their evaluation an order of magnitude cost for each component. This inclusive planning approach also provides a logical framework for hospital staff to implement the strategic plan once it has been evaluated and approved.

To help illustrate this integrated (or holistic) approach, consider this scenario: a hospital selects a strategy of becoming the best cardiovascular "Center of Excellence" in the state by 2012. The goals may be as simple as hiring five new cardiologists and adding ten new beds to increase the number of interventional cardiac procedures to 10,000 within the next two years. Using an integrated approach, the key stakeholders will have data to support the strategy (increasing utilization and hence, revenue). Adding a qualified architectural firm to the mix of stakeholders will test the assumptions of these actions with a multitude of questions:

• Are new beds really required to handle the potential patient admissions?
• Can changes be made operationally to accommodate growth goals (e.g., inter-departmental sharing of exam rooms or extended hours)?
• Has the hospital studied the impact this projected increase in patient days will have on the laboratory services and imaging departments or other key support departments?
• Has the hospital overestimated or underestimated space requirements?

A holistic approach to strategic planning will increase the success of implementing the plan. Increasingly, architects are being asked to be thought leaders in the health care industry, especially around the issues driving facility use strategies. The following list briefly describes what a "value added" architectural team can bring to a hospital's strategic planning process and the real merit of using a holistic approach to completing the plan. A qualified architectural team can accomplish the following:

• Lead a dynamic process that brings diverse individuals who may have divergent opinions and agendas into alignment around a health care facility design supportive of their individual and collective best interests.
• Exhibit experience in directing, interpreting, and implementing standard industry forecasting tools, such as demographic analyses and forecasts. A qualified architectural team will understand how to translate these reports into space programming requirements and projected construction budgets.
• Conduct operational analysis and process redesign by working effectively with nurses, physicians and other clinical staff.
• Coordinate efforts with CFOs to generate and understand the impacts and goals of business plans.
• Demonstrate familiarity with local, state, and federal licensing requirements and the guidelines of The Joint Commission.
• Apply "lessons learned" from a wide variety of commissions to a hospital's specific needs because they possess broad health care design experience, including the planning and design of many sizes and types of hospitals and all departments within a hospital.

Constantly evolving
Health care technology, practices and policies are constantly evolving. High turnover within the administrative and patient care teams is a disruptive factor at many hospitals. A consistent relationship with an experienced architectural firm and consulting team can guarantee constant space planning and evaluation, provide institutional memory, and help a hospital stay on track as it updates its facilities to meet strategic planning goals—or make mid-course corrections if necessary.

In today's highly regulated health care construction industry, architectural directives such as patient or surgical wing additions take longer to implement than the single-year strategic plan timeframe allows. Architects with well-rounded experience can provide a health care facility with the quickest route to durable design decisions, saving time and money as a project progresses from design development and documentation to final approval.

Terrie Kurrasch is a member of the leadership team of the healthcare practice for Ratcliff, a planning, architecture and interiors firm. She can be contacted at tkurrasch@ratcliffarch.com.