Be prepared ... to adapt quickly.

"Be prepared." The old Boy Scout motto pre-supposes a world in which things happen, statistically abnormal things--storms, fires, heart attacks, stock market crashes, global warming. A good Scout learns to build a fire, deliver a baby, write Web pages in Morse Code, knit a pre-frontal lobe, whatever it takes.

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The first step in being prepared is trying to imagine the crisis for which you are preparing. Allow me to propose a few. Each of these scenarios has the capacity to profoundly change health care in the U.S.--most of them in a relatively short time frame, with significant movement within the next 24 months. None of these is farfetched. All are based on real drugs in the pipeline, real policy shifts, real political trends.

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What if a relatively inexpensive drug came out that could prevent much atherosclerosis and shrink and stabilize existing atherosclerotic plaque, obviating the need for many bypass operations and cardiovascular interventions? Such a drug (AGI-1067 from Atherogenics) is in the last stage of human testing, with the results expected by the second half of this year. If such a drug were effective and widely accepted, what might be the effect on your institution's bottom line, program development and capital plans?

More generally, what if both cardiovascular disease and many cancers come increasingly under pharmaceutical control? An array of other cardiovascular drugs and cancer drugs (including especially the dendritic vaccines) are showing great promise. If the coming five and 10 years show a marked shift away from surgical and interventionist techniques in favor of pharmaceuticals, how would that change your institution's budget, work flow, and strategy?

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What if diagnostics move upstream, with new technologies moving many imaging and genomic analysis techniques from the hospital and lab into the doctor's office or even into the home? Simplified gene and protein analysis packages, compact digital X-rays and a number of other technologies are already moving us in this direction.

What if something like Star Trek's medical TriCorder is developed for home use? A number of the technologies that would allow such devices (such as real-time genomic analysis) are in lab development right now and could find their way into compact devices within the next few years. How much of the work of your institution could be replaced or reduced by the use of such devices?

What if lawsuits or legislation effectively eliminate the difference between what you charge the insurance company with the best deal and the uninsured walking in off the street? That was the substance of last year's settlement in Minnesota: The uninsured, the private payers, get your best deal. Hospitals are targeted by many similar lawsuits and pieces of legislation across the U.S. Large price differentials may soon be a thing of the past.

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What if, following a trend both at state and federal levels, not-for-profit institutions are mandated to provide charity care equal to 8 percent of their revenues? That is the thrust of a law currently under consideration in Indiana--and of federal Senate hearings recently called by Senator Charles Grassley, R-Iowa.

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What if the decisions by Beijing and several other East Asian economies to de-couple their currencies from the dollar and slow down their massive re-investment of trade imbalance dollars in long-term dollar-denominated instruments, coupled with Teheran's opening a Euro-denominated oil bourse (undercutting the dollar's role as a safe harbor), cause rates in the bond market to rise steeply, squeezing hospitals' ability to raise capital?

What if your institution ends up in one of the bottom two quintiles in the HCAHPS patient satisfaction survey results to be posted on www.hospitalcompare.gov? This is not Lake Wobegon. We can't all be above average. Lay boards often feel that they do not have the expertise to second-guess how management is handling clinical quality. But customer satisfaction is different. Boards of low-rated hospitals are going to demand change on a FedEx schedule.

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What if large, highly rated medical centers in India, South Africa, the Philippines, Malaysia, Singapore, and other nations team up with U.S. insurers and employers to offer such major schedulable operations as bypass grafts for one quarter of what you can afford to charge? This is a pitch they are already making, with increasing aggressiveness.

Your patients may soon be hearing a discussion like this from their insurers: "Yes, Mr. Heffleburpis, you can certainly get that personality transplant, and we will cover it. You can have it at any hospital of your choice--but of course you will have to pay the $7,000 deductible on your consumer-directed health plan. On the other hand, we have a contract with a wonderful medical facility in Thailand. If you have the operation there, we will pay from the first dime, plus transportation and hotel for you and your wife--and next year, when you are all healed, we will give you a vacation in Thailand." How would such enticements affect your institution's patient flow and strategies?

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What if, because of the growth in health savings accounts, the financial services industry gets heavily involved in advising your potential patients how to spend their health care dollars? The industry is already involved in providing debit cards and other instruments. Employers are likely to follow a path much like what they did with 401Ks, being very paternalistic at first, but gradually backing away and leaving the employee to make their own decisions. This will leave an advice vacuum, one that financial services organizations will be happy to fill--and they are not likely to think the same way that health care people think.

Add to that list the low probability but very high impact of a flu pandemic, plus other risk vectors that may apply only to your sector or regional market. How can an institution "be prepared" for all these possibilities? How do you build a strategic plan that accounts for them all?

You can't, and you shouldn't try. You can build something else instead: Your organization's capacity for learning and dealing with change. An organization with a systemic, organized, formal, organic capacity for learning and adapting not only will survive these changes, it will thrive. The keywords here are "knowledge management," "sense-making," "competency transfer," and "lean production."

Knowledge management is the purposeful management of the flow of information into the specific communities of information within your organization (such as your hospitalists, your admissions group, or your security team), using such tools as online forums, face-to-face meetings, document flow, idea fairs and task forces.

Sense-making is a part of this effort: The digestion of data and ideas by a group (say, OR nurses working on a facility upgrade) to turn them into something that "makes sense," that is useful knowledge, relevant, timely, that solves an urgent problem.

Competency transfer rests on the notion that somebody already knows how to do whatever your group is attempting to do. It might be someone in your organization, it might be some outsider. How do you locate that competence and "transfer" it into your organization?

Lean production is a tool set exemplified by the famous "Toyota Production System" which a number of hospitals are implementing to force positive change--higher quality, lower cost and an improved patient experience. They look at every process in the hospital in detail to ask, "Is there a way that we could do this better, faster, cheaper?"

These are the methods that mark out the future of health care: Under adaptive pressures, health care organizations will, of necessity, become adaptive learning organisms.

Joe Flower is a nationally known health care futurist and CEO of Imagine What If, Inc., which is building the new online world for health care executives, the Healthcare Futures Exchange. He can be reached at [e-mail]