by Tom Nolan, IHI Senior Fellow

The Institute for Healthcare Improvement (IHI) uses a simple mantra to describe the essential elements for strategic improvement: Will, Ideas, and Execution. You have to have the will to improve, you have to have ideas about alternatives to the status quo, and then you have to make it real — execution. This four-part IHI.org article series proposes a system of execution aimed at achieving unprecedented and sustained results at the system level.

Read Part 1, Part 3, Part 4

Part 2: Achieving Breakthrough Performance: Setting Goals and Developing a Portfolio of Projects

A proposed system for achieving breakthrough levels of performance contains four components:

1. Setting Breakthrough Performance Goals
2. Developing a Portfolio of Projects to Support the Goals
3. Deploying Resources to the Projects That Are Appropriate for the Aim
4. Establishing an Oversight and Learning System to Increase the Chance of Producing the Intended Results

This article addresses the first two components of this system.

1.  Setting Breakthrough Performance Goals

Strategic and business planning produces a set of goals for the organization. Often, goals related to the organization’s financial health are prominent. These financial goals are usually accompanied by goals relating to the markets the organization intends to serve and the quality of its products and services. In addition to the financial goals, health care organizations set strategic goals related to patient safety, clinical quality, and patient experience. In its Pursuing Perfection initiative, IHI has developed a set of system-level measures and goals, referred to as the “Toyota specifications,” to illustrate the level of ambition and scope of a breakthrough goal (see Tables 1 and 2). For example, a breakthrough goal for efficiency consists of assuming responsibility for the total cost of care — cost per capita — rather than a specific component of care such as hospital costs, length of hospital stay, or cost per case. Setting aims regarding total cost requires that design concepts relate to the total system or linkages between components such as hospitals and long-term care facilities. The aim might be made more manageable by setting a boundary for the population under consideration, such as cost per capita for very sick persons with multiple chronic diseases.

Consider “Hospital Readmission,” one of the measures in Table 2. Achieving breakthrough performance for readmissions requires redesign across organizational boundaries. The new system likely would include new ways of integrating the hospital, home care, primary care offices, and the family that center on the unique needs of the individual patients. 

Pitfall

The executive attempting to set breakthrough performance goals will often encounter resistance to the ambition of the goal. One response to this is to reduce the ambition of the goal by moving to a lower level in the system requiring less need for integration — for example, cost per case in a hospital rather than total costs; or by restricting the time and circumstances — for example, only including readmissions within 14 days for the same disease as the original hospitalization.

Suggestions

• Keep the discussion centered on the patient’s experience over time.
• Use the Toyota specifications as a comparison for the level of ambition in an aim.
• Concede that one project may not be sufficient to accomplish the goal. Provide some guidance as to how the aim might be accomplished and help establish a portfolio of projects capable of achieving the aim.

Pitfall

With so many opportunities for improvement, the urge to set too many goals and under-resource them will be strong.

Suggestions

• Keep the goals at an ambitious level with respect to impact and scope. This will help people realize that accomplishing even one or two of these goals would be a substantial achievement.
• Face the reality of past achievements. It is a rare organization that accomplishes even two breakthroughs in performance at the level of the Toyota specifications in a year.

Table 1: Toyota Specifications — System Level

Table 2: Toyota Specifications — Component Level

2. Developing a Portfolio of Projects to Support the Goals

Translating the strategic goals to a portfolio of projects presents a problem of proper balance and focus. One of two approaches was used by the organizations that we talked with to establish a portfolio of projects:

1. Start with a breakthrough goal; articulate the means or drivers that are critical to achieving the goal; and then choose projects that as a group are sufficient to accomplish the goal.
2. Start with strategic priorities such as patient safety, community health, financial sustainability, or best outcomes; elicit suggestions for projects in each of the strategic categories; narrow down the projects through a process of negotiation and analysis; and set aims for each of the projects.

Both of these approaches have merit. The first emphasizes integration of effort to focused goals. The second provides some assurance that all strategic priorities are receiving some attention. In practice, some combination of the two approaches may be best.

The first approach to developing the portfolio of projects uses a “cascade” from the goal to drivers in a series of steps, until projects of reasonable size can be identified. Consider a goal based on the  Dartmouth Atlas measures of care for very sick patients with multiple chronic diseases. Figure 1 below is a driver diagram relating system components and processes to the three primary outcomes related to utilization.

The cascade begins with a system-level goal. To provide an informative link between the goal and operations, the goal is accompanied by the means or drivers to accomplish the goal. It is the executive team’s responsibility to ensure that the goal is connected to drivers. In this example, four primary drivers have been identified in Figure 1: hospital care, coordination of care, patient and family support, and supply of resources (provider supply). Each of the drivers could be thought of as a goal assigned to one or more persons with its own set of secondary drivers. The person or group responsible for the primary driver is also responsible for establishing the set of associated secondary drivers. For example, for hospital care, the responsible executives, perhaps high-level medical and nursing executives, have chosen three drivers: use of intensive hospital services, identification of patient wishes with respect to end-of-life care, and timely referral to palliative care services.

Figure 1: Breakthrough Goals and Drivers

Assume that an organization had a breakthrough aim of being in the lowest 10 percent with respect to utilization of health care services by taking a more patient-centric and efficient approach to care. Assume also that Figure 1 outlines their theory of what drives appropriate utilization in the last six months of life. The organization has several ways to pick a group of projects consistent with their aim, theory, and capabilities. The decision process will include some balance of analysis of data, intuition, and negotiation of interests. Different organizations and leaders will weight these inputs differently. Some examples of project portfolios include:

• Four large projects, one for each of the primary drivers
• Three projects for each of the primary drivers except “provider supply” (The organization may believe that more “will” needs to be built in the medical community before taking on this driver or better ideas are needed about how to deal with oversupply.)
• Three projects: one for inpatient, one for outpatient, and one for coordinating between them
• Several projects that are patient-centric and address all the drivers, each of which addresses only a segment of the population (The segments might be chosen by type of disease, disease severity, or the level of support that the patient has from his family.)
• Five projects at the secondary driver level, identified by studying the secondary drivers and finding the ones that are predicted to the have the most impact on the aim

Some organizations will prefer to start with some strategic imperatives and decide on projects that provide good coverage of the imperatives rather than a breakthrough aim. For this approach, the driver diagram or some other method for articulating how the projects connect and what system measures are likely to be affected will still be useful for organizing an efficient overall approach to execution.

Regardless of the portfolio of projects, a process is needed to deploy resources to each of them. In addition, an individual or an oversight group will need to integrate the changes that are made in each project into an optimized system aimed at the goal. These topics will be the subject of Part 3 of this series on Executing for System-Level Results.

Next: Part 3 in the series, Achieving Breakthrough Performance: Deploying Resources and Providing Oversight

Related stories in this series:

Part 1: Organizational Approaches to Execution — Inside and Outside of Health Care

Part 3: Achieving Breakthrough Performance: Deploying Resources and Providing Oversight

Part 4: System-Level Impact of Local Improvement

01/29/2007