Facilitation of strategic planning for a practice can be challenging due to demands of everyday practice. In fact, the National Medical Home Demonstration Project reports that few practices, including ones embarking on large scale medical home transformations, actually take time to conduct strategic planning and collaborate on the direction of the practice. However, the ability of a practice to rapidly enact longitudinal change is largely a function of the practice's adaptive reserve, which is predicted by protected time for reflection on the practice's function and direction. (Nutting et al) As a result, protected time for strategic planning and quality improvement promotion is essential to the success of any clinical endeavor involving the practice team.
Strategic planning should start with the discussion of a practices mission and vision statements. The mission statement should concisely communicate the purpose of the practice and practice goals. It should serve as a directional statement that is somewhat static over time. Conversely the vision statement changes longitudinally and is a synopsis of what the organization wishes to become.
After examining mission and vision statements, it is important to identify needs of various stakeholders in the practice, including staff, patients, and community. It is helpful to have compiled feedback from stakeholders prior to the strategic planning process. Commonly used tools include:
- Baseline medical home evaluation indices
- Patient satisfaction surveys
- Community needs assessments
Strengths, weaknesses, opportunities, and threats (SWOT analysis) both internal and external to the practice should be discussed. The TNAAP tool Strategic Planning for the Medical Home serves as a template recording for these first steps of practice analysis.
Practices usually identify many more opportunities for change than can be realistically enacted. As a result, it is important to identify resources that may be available for change. This not only includes financial resources, but excess staff time, special staff expertise, community resources, space, technical resources, and grants. Once resources are identified, it is important to narrow potential quality improvement goals and resources for measurement against a tool that assesses the goals' fit with mission and resources available. The MacMillan Matrix was designed as a tool to assist not-for-profits in assuring appropriate distribution of resources toward projects most in line with an organization's mission and values and the most consistent with community needs. Utilization of the MacMillan Matrix allows the practice to narrow the scope of medical home objectives to those that are most pressing, most mission centric, and most likely to be achieved with resources available.
The Strategic Planning Guide developed by TNAAP serves as a resource by which practices can record their strategic planning activities and conclusions. Then Agency for Healthcare Quality Research has also designed a toolkit to assist practices with quality improvement cycles- see ICIC Toolkit.
After practice objectives are identified, each objective can be achieved utilizing a Plan/Do/Study/Act (PDSA) framework. This cycle allows structured plan of change with subsequent analysis.
Best Practices in Coordinated Care - Mathematica Policy Research, Inc. March 22, 2000
Once general strategic analysis of the practice has identified and prioritized objectives and resources, the next step is the Planning part of the PDSA cycle. In this step, strategies for achieving objectives should be planned. These strategies should take into account the resources available for achieving the objective. Close attention should be paid to the evidence-base that might support or disprove the strategy's ability to impact change. Achievable goals under each strategy should be listed. Finally, quantifiable metrics by which attainment of the objective will be measured need to be outlined ahead of time. If a tool will be used to collect this data, the tool should be identified at the beginning of the project. Neglecting identification of metrics is the mistake many practices make in planning quality improvement interventions, leaving little other than anecdotal evidence that strategies actually achieved the objective identified. Documentation of change can be important evidence used to impact contracting and fee schedules with payers. TNAAP staff can serve as a resource for metrics that have been used in local quality improvement projects.
After setting metrics, it is important to identify staff roles in different strategies and set timelines for benchmarks. The objectives and strategies should be clearly communicated, as should staff members' roles in each intervention. Timelines for the overall objective as well as for individual staff member should be set. Solicit feedback from responsible parties concerning potential needs, such as training, tools, IT resources, and other needs. Each objective should have a project coordinator as well as a physician champion identified.
TNAAP Strategic Planning Progress Tracking Template
It is important to set clear timelines and communicate objectives and strategies to all staff members, even those not involved in achieving a particular objective. Project coordinators should check in with each responsible party at least once every other week to monitor progress, solicit needs, and gather feedback in case changes to the strategy need to be made prior to the next team meeting. Team meetings consisting of all involved staff, project coordinator, and physician lead should occur at least quarterly but preferably at least every 8 weeks. These meetings are times for celebrating successes, as well as for group troubleshooting of areas where anticipated progress is not being made. It is important to be open to changing timelines or redistributing resources if unrealistic goals have been made. It is often the case that the full scope of resources or time needed to achieve a particular objective is not apparent until change toward the objective is being made. The team should discuss observations of progress toward the objective, including progress as measured by metrics.
The TNAAP Strategic Planning Progress Tracking Template will serve as a tool for recording progress toward objectives and for promoting accountability.
Information for the Study phase of the PDSA cycle should be chronicled during all phases of the PDSA cycle. Unanticipated barriers and successes should be described, and longitudinal progress should be measured. Final data compilation should occur during this phase. The team should be involved in offering feedback on final data parameters. Conclusions drawn from data collected should be recorded.
Conclusions drawn during the Study phase of the PDSA cycle serve as the foundation by which future plans are made toward the objective. If the strategies employed were effective, the strategies may need to be incorporated into the processes of everyday care at the practice. If some progress was made, but the objective not achieved, discussion on how to change strategies might reveal a way to improve them so that objectives are achieved. If no progress is made toward objectives, analysis of the root cause of deficiency and the evidence base for the strategy employed may be considered. All of these processes may lead to adoption of strategies long-term or change to different strategies over time. These conclusions are the starting point for a new PDSA cycle.