Decisions on the Double.

Leading together in an accelerated environment.

Editor's note: The American Academy of Orthopaedic Surgeons (AAOS), Rosemont, Illinois, is an early adopter of a number of the ideas presented at the November 2000 associations: digitalNow Internet strategy conference, cosponsored by Fusion Productions, Webster, New York; Walt Disney World Company, Orlando; and ASAE. Held in Orlando November 2-4, 2000, the conference focused on helping associations reshape their business models and redefine their competitive advantages to capitalize on opportunities offered by the digital age.

Starting to work with Fusion Productions in 1999, AAOS has been addressing issues relating to technology, the Internet, and the Information Age that its leadership sees as critical to the association's continued relevance. This article launches ASSOCIATION MANAGEMENT's in-depth coverage of the conference, which will continue in the February and March issues. Co-authored by Lawrence E. Rosenthal and Richard H. Gelberman, the article is presented in Rosenthal's voice for purposes of clarity.

Late in 1999 (eons ago in Internet time), the American Academy of Orthopaedic Surgeons (AAOS), Rosemont, Illinois, recognized that times were definitely changing. We were seeing several emerging trends: new generations of members with different value sets, volunteers willing to contribute ever-smaller amounts of their time, and increased competition at our doorstep. We were hearing more often the question from members: "What value am I getting from the academy?" At the same time, both our staff and board had to admit that the organization had not been changing. As the largest orthopaedic society in the world--with a membership of 24,650, an annual budget in fiscal year 2000 of $36 million, and a staff of 225--even this 1,000-pound-gorilla of associations had met its match.

The numerous challenges to the organization appeared to be based on two phenomena: the impact of new generations and the effects of the Information Age. For example, while we were collecting all kinds of information and posting it to the Internet, we were more focused on our members' needs--and not the needs of the members' patients. The patients, in fact, had become quite sophisticated about searching for answers on the Internet and then bringing the information in to the surgeon's office. They had more information than their doctors did.

Meanwhile, in "The AAOS in 2005 Workshop Report," recapping the work of our initial planning group in Chicago, October 29-30, 1999, a significant paragraph appeared in the beginning pages. "...the presidential line approved an initiative to be led by Richard H. Gelberman, second vice president, to begin a 15-month study to address the significance of the upcoming changes for the AAOS. Gelberman is charged with developing strategies and an action plan to position the AAOS to be a leading professional musculoskeletal physicians organization in the first decade of the next century." Following was a hefty list of objectives for the initiative, known as The AAOS in 2005. (See sidebar, "Objectives of The AAOS in 2005 Initiative.")

The 15 months are drawing to a close--and during that time the board and staff of our organization have covered a lot of new and sometimes unsettling territory. We've challenged our institutional culture, redefined our core values, and begun to change the way we do business. In doing so, we've also been forced to confront a decision-making process that was designed for a different time--a time when things did not move as fast, members had more time to give, and technology solutions were in their infancy. We are also figuring out one of the key elements of organizational effectiveness in today's world: Our staff and board are learning how to work together to make decisions in the accelerated time frame demanded by the Internet Age. By the time of our February 2001 board meeting, Gelberman will be prepared to present the results of the 15-month journey: the proposed vision, mission, and organizational model of The AAOS in 2005. Here's how it all came about.

First steps

Our recognition that change was in the wind was not based on one, single, cataclysmic event. Rather, it was a series of things that, as we looked forward, seemed to have the potential to threaten the academy's position as the preeminent provider of musculoskeletal information in the orthopaedic community. Specifically, we recognized trends in three areas.

* Narrowing revenue sources. With only about 25 percent of revenue coming from membership dues, we've relied heavily on revenue from exhibits at our annual meeting and from our various educational products. With significant corporate consolidations among pharmaceutical companies and medical device suppliers, we began asking ourselves if the industry could continue to support the same volume of exhibit space as it had in the past. At the same time, trends in managed care were affecting the decision-making status and the discretionary income of members (both in private practice and in academic settings)-- developments that we viewed as a threat in terms of the amount of educational materials members might continue to purchase from the organization.

* Delay in moving from concept to product. We continued to use a deliberative process that had been effective in an earlier era but was no longer workable in the fast-paced environment driven by advanced technology and the Internet. Typical of organizations of our size and mission, we would assign a task force to research an idea that might have bubbled to the surface. Our task forces, by definition, were designed not as implementing bodies but as groups charged to study an issue. The task force would usually take 6-9 months to develop study results and a recommended approach on how to proceed. Then an implementation committee would take another 6-12 months to implement the proposal. A lot of what we've been doing now is to try to make the transition into a faster moving process.

* Changing needs of members. AAOS First Vice President Richard Gelberman, who will be named board president in March 2001, also began recognizing that the next generation of orthopaedic surgeons--and our source of new members--were all computer-enabled, very facile with obtaining information online, and hungry for even more information online. As Gelberman observed, "Those three factors seemed to be coming together like the perfect storm; they were impacting us every time we turned around, and we felt that we had to get our hands around this trend and--in a more strategic sense--understand where our organization needed to go if we were going to be leaders by the year 2005."

Revolution by evolution

The knowledge management issue began to resonate with Gelberman in 1997, when he was council chair for education. He and I had many discussions about how we might organize data and information in such a way that created knowledge applicable by the individual orthopaedic surgeon to his or her own practice. Philosophically, we were trying to give back to members the time it would take them to figure out what all this information meant to them. Because of our numerous conversations on this matter, all of a sudden things began to click. We talked more and more about it, and Richard began to see that these strategic shifts might well be the basis for his year as president of the AAOS board, the term of which begins in March 2001. What happens traditionally is that during the two-year run-up to the presidency of the board, the designate is identifying initiatives and agendas. The main work that Gelberman has taken on--positioning AAOS for 2005 and beyond--began back in July of 1999 when he was still second vice pre sident of the board.

Our shared goals developed into an evolutionary process--both in the working relationship between Gelberman and I and in the development of a strategic process for the organization--that sparked a series of planning meetings that have set the stage for a major revamping of the organization.

The factors that Gelberman had noted about the newer generation of AAOS members with regard to technology issues were part of what inspired "The AAOS in 2005 Workshop" in late 1999. As Gelberman looked at what factors were affecting the academy, he was interested in taking a more strategic approach to those kinds of issues and in revisiting how we made our decisions.

A methodical process

The first milestone at the October 1999 conference was the convening of a cross-generational work group of senior fellows, current academy leaders, surgeons who had been in practice for some 20 years, new fellows, orthopaedic surgeons in fellowship programs, and representative senior staff members. It was a beautiful dynamic to see a former president of the American Academy of Orthopaedic Surgeons sitting among--and brainstorming with--young doctors, creating hypotheses about what initiatives needed to take place.

The members of the work group were charged as active and equal participants in the conference's deliberations. It was the start of a dialogue that would eventually be part of the change dynamic at AAOS.

A number of broadly defined next steps evolved from the conference:

* Redefine core values.

* Change the way we will do business.

* Make the Internet a major strategy.

* Be in the knowledge management business.

* Focus on individual member needs.

Other follow-on activities included research on possible new organizational models as well as a special workshop of the AAOS in 2005 team in which team members would discuss the options for such models--and assess the impact on our current governance structure.

To make it all happen, we knew that we would have to pull out all the stops. With an individual membership organization of our size--along with the board of directors and a staff of 225 who also had to be shepherded along--we needed a game plan.

Taking staff-based steps

We identified the follow-on steps articulated at the October meeting that the staff would be responsible for, and then we laid out an overall project plan with time lines and specific functional milestones. The plan included the following directives:

* Formulate hypotheses as to our core business activities and the nature, needs, and expectations of members.

* Test the hypotheses through a rigorous study of the various groupings of members and develop a list of their expectations.

* Design prototype pilot initiatives to address needs and expectations of all member segments.

* Test drive the initiatives through focus groups and an initial implementation cycle.

* Evaluate the results of the test drives.

* Conceptualize an idealized organization for 2005 that will fit our functions.

* Develop strategies and tactics to overcome the hurdles to achieving this kind of ideal organization.

* Secure board, member, and staff buy-in.

* Develop the final implementation plan.

* Begin implementation.

From the beginning, we planned to report our progress at each of our three hoard meetings throughout the year and to provide a brief follow-up summary to attendees at our annual meeting.

The main goals that staff were to tackle included several cultural shifts that would eventually provide the basis for a kind of staff-volunteer model that would expedite decision making, more effectively identify relevant business opportunities, and empower staff for the benefit of the membership. We immediately began to experiment with teams composed of members and staff. For example, if we are to be a competency-based organization, we need to develop a database that captures information that helps us identify those of our members and staff who actually have the competencies we need. Consequently, one of the teams will represent all levels of staff--as well as a selection of members--who reflect those competencies. I appointed the team leader, but the leader then selected the people to make up the team.

To work on developing our ideal organizational model, one team has named itself The Gaps Team. Again, a representative team of members and staff will review the current organization and identify gaps that must be filled in order for AAOS to fit the idealized organizational model.

While expediting the staff-team partnership to get this entire process out of the starting gate, I began to bring in carefully selected experts to lend credibility to our plans and to ease the transition to The AAOS in 2005. This influence was coupled with another key strategy for building staff understanding: publishing a series of articles in the staff newsletter, "No Bones About It," describing in detail the goals and initiatives that we were planning.

Following are some of the key elements of the ensuing staff activity.

Establish an evidence-based methodology and a discipline for AAOS based on a parallel track with clinical medicine. We decided to identify our best management practices in the same way that the medical industry identifies best treatments--through studying a series of cases or outcome studies that evidence the fact that this is the way to do the particular procedure. Rather than creating elaborate and expensive products (or organizational changes) based on ideas informally thrown out for consideration at the October workshop, for example, we would develop an evidence-based discipline that says an idea is not golden until it gets validated by some research.

Apply the discipline by conducting market research activity on the assumptions presented at the October meeting (narrow revenue streams, delay in moving from concept to product, and developing needs of the membership). We did this by starting with focus groups, composed mostly of orthopaedic surgeons who attended AAOS training courses and professional programs. Rigorous market research activity was supplemented by a follow-on survey of a statistical random sample of members. Based on focus group results and the survey, an outside firm created several hypotheses that promised a standard error of measure of no more than 3.5 percent.

Identify principles (supported by the research) that articulate the outcomes of this effort and become the basis for the overall strategic plan. In various meetings and workshops, the staff--with a certain amount of board involvement--arrived at key principles that would constitute the major outcomes of this effort. The key principles that we have identified at this point include 1) establishing a staff-volunteer dynamic that becomes a basis for moving forward; 2) developing a board of directors that is competency-based rather than constituency-based; 3) making the commitment to involve our youngest members, those who are more computer-enabled and who have the characteristics of the next generation of orthopaedic surgeons; 4) becoming an evidence-based organization that makes decisions based on data; and 5) revising our organizational structure so that we become a more horizontally integrated entity.

Getting the board on board

Gelberman and I thought a lot about how we would achieve board participation in this whole process and what it would take for them to embrace--or at least accept--some of the more sweeping changes. Several things seem to be working well.

Information dissemination. Immediately after the October workshop, Gelberman began what he calls an information drip, a steady stream of information about the various aspects of this program that we were undertaking. His goal was gradually to make board members aware of the terminology we would be using, the unsettling trends we had recognized, and the early efforts we were undertaking to deal with this new environment. A follow-up workshop in April 2000 further educated the board on the perceived needs of AAOS in order to remain relevant. Much of the programming for the 3 1/2-day meeting was the reporting of the outcomes of the research done to substantiate our assumptions about the need for new revenue streams, the importance of becoming a technology-and Internet-based organization, and the different needs of new generations of members.

Gelberman and I both noticed, perhaps predictably, that there was quite a variation in response to the information presented. Some bought into it early on and became active, enthusiastic supporters of the overall concept of revamping the academy. Others hung back, not quite sure how to respond. After all, this was an entirely new process for the board and they weren't quite sure how to take it and where it might be going. Naturally, some were concerned because this was not at all typical of our former ways in which someone would come into the room with a set agenda, put it forward, and board members were either for it or against it. Our new process requires stepping back a bit, looking at the background information and data-- and some were not so comfortable with that approach. But as the meeting went on, most people became more convinced that this new process was going to move the organization forward in a direction that it should be going.

Active involvement. To further bolster the information drip, we involved some of the members of the board in two focus groups so that they were actively involved in the decision-making process determining how we would move forward. Eventually, a workshop (in April 2001) will involve the entire board in dealing with these issues.

Decision making. To further foster participation of board members, we schedule breakout sessions at the various workshops and meetings and involve several members of the board at a point where they can actually participate while decisions can still be made. This is usually during the time that we've developed principles that participants in the meeting will then flesh out with more detailed plans.

Integrating staff and board

Gelberman would be the first to point out that the process launched at the October workshop is one of the first models in our organization where staff and members met on an equal footing and were openly discussing critical issues for the organization on those terms. In the various workshops and meetings that have followed, participants have included representation from the board of directors, other volunteers, and staff. We try to select volunteers who show competence in certain areas and match them with staff members who complement those qualities. It has been an effective model, and we hope that it will become a part of our new organization, paving the way for improved appreciation for the contributions of staff and members and where all will have an opportunity to contribute.

Building up speed

Throughout the planning process, we've been learning more and more about streamlining the way we work. And while it seems that some of the time taken for the evidence-based process, for example, slows us down, in the end we believe we'll save significant amounts of time by not developing projects that ultimately are ineffective or unsuccessful.

Another point we should make is that by the time of our June 2000 board meeting--only seven months after the October planning workshop--we had already developed a series of pilot projects based on our assumptions and research findings. With our old operational model, we would never have been able to get that far. In fact, we were able to present some of these pilot projects to the board at that time, with requests for authorization for human and financial resources. We plan to test drive the pilot projects, show the results to members, and then make the modifications that we need to make from what we've learned, Only then will we commit to developing the actual products.

To achieve the speed that we hope to increase even more across time, we've relied on some tried-and-true techniques and have further plans for some methods we have not yet employed (see sidebar, "Techniques to Increase the Tempo," for a summary of current techniques and those planned for the future). Things we have tried so far include:

Assign active staff liaisons with defined responsibilities beyond meeting planning. Even in our existing structure, we assign staff liaisons, some with multiple committees assigned to them. These resource people work directly with committee chairs. Our vice president of education developed a staff-liaison training program and, recognizing that staff changes from time to time, put the material on the association Intranet so that it is available to new people as they take on a new liaison assignment.

The staff-volunteer partnership has been a good technique for us as a means to identify those decisions and initiatives that will have implications for staff--and as an ongoing information resource for both staff and volunteers.

Use mail or e-mail balloting. The AAOS board of directors is not only using e-mail for board communication, but Gelberman made sure to immediately set up a special listserver to discuss The AAOS in 2005 issues after the October workshop. The e-mail list allows the board to quickly poll members for opinions on key questions. E-mail is also the primary mechanism by which committees conduct business. When new committee appointments need to be made quickly, for example, resumes and curriculum vitae can be solicited via e-mail, reviewed, and evaluated as a means of selection for committee chairs. The decisions can be made in a matter of days, rather than in several Months--which is what the process used to take. According to Gelberman, the board does balloting by e-mail and makes use of e-mail at all levels to expedite decision making.

As for other uses for e-mail, we expedite focused committee activities, and our members routinely submit articles and presentations electronically. After 2001, electronic submission of abstracts for the annual meeting will be the exclusive method of delivery.

Get meeting minutes or summation reports out within 10 working days after the meeting. Not only are proceedings more likely to be better documented, but having the action items in writing--and accompanied by a simple monitoring technique (see next point)--motivates those responsible for them to move forward in accomplishing the articulated goals.

Identify what follow-up actions are needed and build a monitoring and follow-up mechanism. After each board or committee meeting, we go through the minutes and pull out the actions that staff and volunteers have identified for follow-up. Assignments are made and outlined on our "Action Follow-up Sheet." This sheet becomes part of the consent agenda for the next meeting.

Prepare interim project progress reports that emphasize progress and/or reasons for lack of progress. For more complex projects, such as The AAOS in 2005 initiative itself, we produce a major report. The workshop report published after the October 1999 planning meeting is exemplary of the types of follow-up we find beneficial in keeping a large project on track. The workshop report section entitled "Next Steps: Functional Milestones" outlined 13 major goals to be accomplished during the 15-month planning period along with time frames for their completion. Subsequent reports summarized the work done toward these goals and the time frames for completing the next steps. These reports are then distributed to all board and committee members, the AAOS in 2005 work group, and others who play a role in the project.

Facilitating the speed factor

While the ink is still drying on the final details of The AAOS in 2005 initiative to be presented to the board next month, the path to its finalization continues to be punctuated with progress in terms of a gradual speeding up of the decision making process. Other techniques we plan to deploy during the coming months include:

Set up a fast-track approval body. Making use of technology, of course, does a lot to enhance the fast-track process. The executive vice president and I conduct a weekly conference call with the presidential line (AAOS's top volunteer leaders include a second and first vice president as well as the president of the board). During these conversations, we discuss issues that require immediate action. If we need to involve the executive committee, we'll include them via teleconference or perhaps we'll do balloting via the Internet to capture their necessary input. Like many organizations, we have our share of volunteers who are reticent to use email, so we put their secretaries and administrative assistants on the alert so that important messages are read and responded to.

Establish time-limited project teams. Recognizing that newer members will not commit to serving on typical committees on a long-term basis, we've developed a concept of project teams. The teams will bring together members and staff in a particular area of competence to address an issue or accomplish a project. After completion of the task, the team will be disbanded. This is quite different from what we ask members to do now, which is to serve on a committee for a period of either three or six years.

Schedule regular teleconferences with leadership and committee chairs. Gelberman also has begun to use teleconferencing as a means of being more inclusive--and to reduce the number of meetings that need to be set up. For example, a recent board meeting conducted in chicago was teleconferenced to our Washington, D.C., office. Gelberman reports that while only two teleconferences have taken place so far, the results were quite positive and the technique will certainly be used whenever possible and appropriate.

Empower staff and board committees by giving the authority to spend funds (with a specified upper limit) on activities without prior board approval. We are already doing this and expect that the practice might be more liberal when the AAOS in 2005 initiative is fully implemented. At this time, each of our four councils is allocated a sum of money for projects. The council chair or the entire council can approve the use of up to $25,000 without any additional approval. To spend more than that, they are required to advise the board. This system seems to work well because it provides empowerment at the level where it needs to be and prevents the board from involvement in the less significant budgetary details. Of course, we'll do periodic evaluations to determine how well this is working with the various councils and determine if any adjustments are necessary.

Combining vision and velocity

So what will AAOS look like in 2005? We believe that board members will become more comfortable with the concept that they can deal with issues on a strategic level and that empowering staff and members appropriately and giving them authority will benefit the organization and allow us to move forward more quickly. We also hope that succeeding board presidents will not think that they have to reinvent the organization but that they can rely on a well-conceived strategic plan upon which to base their agenda.

We know that the relationship between the board and staff that has grown out of The AAOS in 2005 effort has resulted in an appreciation on the part of both groups of the competence and abilities of the other. This partnership has demonstrated to the board, in particular, that we have not completely taken advantage of the capabilities, intelligence, skills, and energy of the staff in the past. Continuing to foster that innate capacity will move us forward more quickly than before.

We see also the creation of a board that is competency- rather than constituency-based. This calls for identifying those areas of importance for the academy and only then approaching individuals with competence in those areas to serve on the board and to provide true value when considering our most important decisions.

As far as the organization itself is concerned, we envision an association that is in the knowledge business, delivering products through the Internet much more than we are doing now. And those products and other decisions that we make will be evidence-based. Like the board, our organizational structure will be competency-based and it will be part of our culture that the staff has a definite leadership role to play in certain areas where they bring expertise.

Not all organizations share the advantage of having champions in both board and staff leadership to work together to bring about major change in the organization.

If the chief elected officer is the driver of the process--or at least an enthusiastic participant--he or she must make a number of commitments in order to move the change process forward. Key among these are the commitments to 1) maintaining a thorough knowledge of the organization and its member needs, 2) establishing an ongoing dialogue with the chief staff officer, 3) adopting a flexible attitude, especially with respect to new thinking, and 4) using delicate but firm negotiating skills to bring people on board with new initiatives.

When there is no clear champion on the board, the association executive must be willing to stand up and be the leader-leading the board as much as possible in the direction he or she sees as right for the organization, while trying to find a champion or perhaps several board members who are willing to listen. The vision must be supported by data and information--and the association leader must he ready to make a long-term commitment to promoting change. There are no templates and there will be no templates for accomplishing effective change.

Regardless of the specific individuals who take on the challenge of markedly changing an organization, I like to quote Machiavelli's The Prince to describe the significance of such an undertaking: "It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system. For the initiator has the enmity of all that will profit by the preservation of the old institution, and the merely lukewarm defense of those who would gain by the new one." At the same time, I feel that if the vision is successful, all of the barbs endured along the way are well worth it.

Every association's environment is different and the particular things that it has and does--including biases, ways of thinking, and views of the future-- are unique. But we would say that it is well worth the effort to undertake the change process, however complex and intense. What we have been working on is a way to focus on those things that will really make a difference and to pursue achievable goals that will move AAOS along at a speed that keeps pace with what the Internet Age demands. By doing that, we can not only improve the way we do things, but we can create an organization that has sustaining value for our members.

Lawrence E. Rosenthal is deputy executive vice president and chief operating officer, American Academy of Orthopaedic Surgeons, Rosemont, Illinois. E-mail: [e-mail]. Richard H. Gelberman is AAOS first vice president and will be named president in March 2001. He is professor of orthopaedic surgery and chairman of the department of orthopaedic surgery at Washington University and at Barnes Jewish Hospital, St. Louis.

Objectives of The AAOS in 2005

In its October 1999 initial planning workshop, the American Academy of Orthopaedic Surgeons laid out its overall objectives to accomplish its broad goal of meeting the needs of the upcoming generation of orthopaedists in the Information Age. The initiative, known as The AAOS in 2005, outlined the following imperatives:

1. Define the impact of the changing value set of the next generation on the AAOS, including the needs of future members of the AAOS.

2. Develop a model that will describe AAOS core values in the first decade of the 21st century.

3. Identify the internal factors (strengths and weaknesses) of the AAOS that will support and/or impede the achievement of the AAOS core values and vision in the next decade.

4. Identify the external factors (opportunities and threats) that may have a positive or negative impact on the AAOS achieving its new vision and addressing its core values.

5. Review the current member organizational structure of the AAOS entities. Identify what changes, if any, should be considered given the changing roles of members and staff working as partners and stakeholders in the AAOS.

6. Define what will constitute success in the near and long term.

Techniques to Increase the Tempo

As the 15-month study to identify and articulate the American Academy of Orthopaedic Surgeons' future unfolded, both board and staff developed a number of techniques that began not only to seal their relationship but to help them accelerate their activities. Here are some of the techniques they've adopted, several of which can be used by the chief elected officer to move this kind of process along.

* Assign active staff liaisons with defined responsibilities beyond meeting planning.

* Use mail or e-mail balloting.

* Get meeting minutes or summation reports out within 10 working days after the meeting.

* Identify what follow-up actions are needed and build a monitoring and follow-up mechanism.

* Prepare interim project progress reports that emphasize progress and/or reasons for lack of progress.

* Set up a fast-track approval body.

* Establish time-limited project teams.

* Schedule regular teleconferences with leadership and committee chairs.

* Empower staff and board by giving the authority to spend funds (with a specified upper limit) on activities without prior board approval.