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How physicians can create their future.

This article responds to the need for physicians to become proactive, using strategic planning to address changing conditions in the health care field. Strategic planning purposes are defined and a common process of strategic planning is presented. A case study analysis includes commentary on the need for planning, the context of planning in a larger system, process and procedure, a sample plan, benefits and actions to date, and future uses of the plan. Implications of this case of strategic planning for other physicians are discussed.

What will the future look like for physicians and organized medicine? Will the future be coproduced by physicians, or it will it be designed for them with elements that may or may not be desired or beneficial? Will physicians continue to be reactive, or will they become proactive, moving to create their desired future?

There are many reasons why physicians and organized medicine should plan. One of the most persuasive arguments is derived from Lewis Carroll as he describes Alice's dilemma in the forest (figure 1, page 32).[1] Without a clear vision of their desired direction and future, what physicians decide on a day-to-day basis--at the individual practice level, at the group practice level, at the academic and clinical department level, at the college level, at the national level--does not much matter. A future will be created, but it will be created for physicians and organized medicine, not by them. Government regulators, some patients, and certainly corporations are concerned about physician and medical care costs. They have in mind a future that they most desire involving close control and limitations on care and cost. The questions for physicians and organized medicine is, Have they designed a desired direction and future and tried to establish ways for getting from where physicians are now to where physicians would most like to be?

The changing pressures on the Johns Hopkins School of Medicine and the Johns Hopkins Hospital led both institutions to create new visions of the future, to establish alternative structures, and to move aggressively to create a future beneficial to both institutions.[2-3] Physicians must be involved in much more of this proactive and assertive creation of their own future. Physicians need to learn more of the processes used for planning, processes that produce creative, exciting visions of new futures.

Why--The Need for Planning There are reasons why individuals and organizations engage in planning. One author identified five reasons as leading points of the rationale:[4]

* Few organizations currently have a vision of a desired future. Some feel an easy extrapolation of the past will do.

* In recent years, we might have relied on a single executive, a single vision of the future, but this is no longer adequate.

* We are increasingly searching for ways to involve employees at all levels in the organization, to improve productivity and performance, and to improve the quality of working life.

* We must design organization futures openly and consciously as a way to generate excitement about where the organization is going. Neither executives nor managers and employees have enthusiasm for a mindless extension of what they are currently doing into the future.

* We need guidance in our day-today decision-making. How will we know which decisions make sense if we have no defined future?

Like Alice, physicians have entered a forest of competing interests, problems, conflicts, and uncertain directions. Strategic planning is a process by which physicians and organized medicine can begin to identify a path through the forest, navigating the forks in the road. Physicians as a group and individual medical departments:

* Need a vision of the desired future.

* Need the ideas and contributions of many individuals.

* Need to involve many constituencies (providers, patients, citizens) in designing the future.

* Need to generate optimism and excitement,

* Need to engage in strategically oriented day-to-day decision making. The purpose of a strategic planning process is to assist the organization or organizational unit in identifying changing external conditions, in identifying internal strengths and confronting weaknesses, and in defining a desired future that the organization members can strive for and achieve.[5] A set of eight purposes more fully describes the rationale for strategic planning. Strategic planning--at the individual medical practice level, at the group practice level, at academic or clinical department level, or at the organizational level leads to:

* Purposeful creation of a desired future.

* Systematic and ongoing review of the external environment.

* Review of position and progress.

* Confrontation of the need for adaptiveness.

* Reconsideration of stated and unstated strategies.

* Increasing innovation and creativity in the organization's production of services.

* Reallocation of resources.

* Organization change and development.[4]

Therefore, the purpose of strategic planning is to help physicians define where they are now, relating where they have come from to where they would most like to be.[6]

In a creative and dynamic strategic planning process, the organization spends as much time attempting to define its most desired future as it does focusing on the present and the past. Most organizations mistakenly assume that planning should be a simple extrapolation of what has been done in the past.[7] Unfortunately, historical review is hardly demanding, hardly creative, and unlikely to be successful in an environment that is rapidly changing and that requires rapid adaptation. Without attention to the desired future, the focus is defensive and on what has been accomplished rather than on what should be done to achieve a valued future.

How--A Strategic Planning Process and Case

There are many models of strategic planning systems. Academics, consultants, and practicing planners have designed and developed processes that fit the unique needs of their organizations. In one view, the process of strategic planning involves eight steps[4]:

Step One-- Planning to plan.

Step Two--External analysis through environmental scanning.

Step Three--Internal review through organizational systems analysis.

Step Four--Creative design or redesign of desired future.

Step Five--Comparison of the current situation and the desired future.

Step Six--Choosing of strategies.

Step Seven--Identifying actions and programs.

Step Eight-Linkage to operations

In a strategic planning process, physicians in any practice setting would create a planning procedure with times, participants, and level of staff support defined; analyze and discuss changes external to the department and the organization; review their internal technical work, e.g. staff support, structure, and operations; envision their future--3 to 5 years from now; compare the present and the future; identify a driving or lead strategy; identify new and revised actions and programs; and create a process to ensure that the plans become operational.

This unique series of steps is something of a generic planning approach. Many planning models include most of these steps except for creative design of desired future. Step Four is specifically derived from the idealized design approach to planning created by Ackoff and colleagues in response to the absence of visions of futures in most organizations.[8] Without a desired future, physicians are faced with Alice's problem--which way to turn, or how to make decisions on issues such as hospital and HMO linkages and staff types and levels.

A Case Study

A clinical department in a university college of medicine engaged in strategic planning in response to recognition of changing external trends and to the creation of a universitywide strategic planning process. Department-level strategic planning was designed to be integrated with an all college strategic planning process that was in turn linked to an all-university process. Department members believed they needed to engage in a creative proactive process that would best prepare them for the universitywide changes.

The department began to plan by recognizing:

* The need to identify its mission and the department's position in the greater organization.

* The need to respond to rapidly changing external conditions.

* An interest in adapting the organization to fit the needs of the clinical discipline, the faculty, residents, patients, and students.

* A desire to involve faculty and staff in designing the organization's future.

The incentive to initiate planning was both external and internal. There was outside pressure from rapid changes in the medical and health fields (e.g., cost, quality, and delivery system developments). There were also internal incentives, as both the medical school and the university were beginning to plan more formally but without much physician participation.

Context--The University Strategic Planning Process. Department planning was conducted in the context of a college and universitywide strategic planning process with the following elements":

* Appraisal, including external and internal assessment in relation to mission.

* Matching, linking program quality and need.

* Setting priorities, defining resource requirements and developing alternative strategies.

* Implementation, creating action plans.

Within this universitywide framework, there was space to tailor college and department level processes, with the requirement that individual plans could be "translated" and linked to the universitywide effort. This department created its own process, relating its plan to the university system at the implementation step. Physicians in the department wanted to be proactive within the university, not reactive to other departments and to administration.

Department Level Planning Process. In response to the medical college dean's charge to initiate department-level strategic planning, the anesthesia department developed a planning process. The summary of the plan represents the integrated work of the department's planning team and review by all faculty with regard to external and internal analyses, future direction, and program actions.

The planning process was designed to generate participation from department faculty through a representative model. Planners met in four group sessions of approximately four hours each, led by a planner-facilitator. Along with the chair, the department's planning team included five senior professors--clinical, education, and research directors representing the major areas in the department.

A successful planning process requires individually tailored design. Following general design guidelines, the planning process was characterized by nine points:

* Size--The strategic phase was to involve a small working group with only departmental leaders involved.

* Involvement--Participants were chosen carefully to represent all division and major department activities.

* Formality-Informality Mix--The process was to be informal, but with regularly scheduled meetings and a formal output.

* Nature of Information--Qualitative data and professional judgments constituted the database.

* Process Support--An external planner was engaged to assist in design and to facilitate the process, with the department chair and secretary coordinating the processes.

* Analytical Approach--No computer support or formal data analysis was used in this stage.

* Cost--The process was not expensive in terms of both consultant costs and faculty time expenditures.

* Time--The first phase of the process was implemented in 30 days.

* Follow-Up--Periodic updates of progress toward implementation were held beginning with a full department review at a day-long retreat.

Four steps defined the procedures in the first strategic phase, with further involvement of additional department members occurring in a retreat some three months later.

Step 1: Current Scenario--An analysis of the current situation, including an external scan, defined as a review of critical issues outside the college-hospital and outside the department (within the medical school); and an internal scan defined as a review of strengths and needs within the department. The internal review considered what the department does well, what needs to be done, and what needs to be done differently?

Step 2: Creative Redesign--A scenario of how the department would be redesigned if it could be redesigned in any way it wanted. This was a creative view of the desired future. The mission for the "future department" was defined and elaborated.

Step 3: Comparison of Future with Present--A comparative analysis of the current scenario with the redesign. What are the gaps, problems, and issues?

Step 4: Strategies and Actions--What strategies and actions must be taken to move from where the department is now (current scenario) to where it would like to be (desired future)?

After these steps were completed, the strategies and action plans were converted to program plans, as identified in the university strategic planning process. A report or "white paper" was developed with an internal and external review; a creative redesign with a statement of primary mission, definition of needs, and strategies and actions to take the department to its desired future. The white paper was distributed to the full faculty. An executive summary of the plan is shown in figure 2, page 35, to provide a sense of both the issues and the directions proposed by the planning group.

The summary includes points that encompass each of the steps of the process--external and internal review, mission statement, desired future and strategies, programs, and actions. The report was both a summation of the first phase and a milestone in the continuing planning work.

The framework enabled physicians to confront the changes in the medical field and the developments occurring within their own university, hospital, and clinical field. Discussions were both thoughtful and intense, as each faculty member and division chief began to consider his or her stake in the future and the degree of fit between the department's emerging direction and personal objectives and interests.

Most important, the design led to stimulating and sometimes differing thoughts about what the future should be and how to get there. This is rarely done in an open and participative way that allows planning team members to codesign with the chair their joint future. Debates involved the extent of effort to be devoted to research versus education versus clinical work. Did the department want to be large or small? Should research be directed toward themes for maximum impact departmentwide, or should any research topic be acceptable and supported? The last question cuts to fundamental concerns about creativity and control in scientific research. Can we plan for research discovery, or is that approach inconsistent with creative freedom? In short, the thinking and the debates established by the structure were the essence of planning--success was defined as people engaged in purposeful design of a joint future.

Continuation and Planning Benefits and Actions. The "strategic white paper" reported on the first round of planning with key departmental leaders. A continuing planning process was developed as a follow-up. After the first planning steps were completed, strategies and actions were converted to program plans as identified in the university strategic planning process. The general findings from the first phase appeared in the report, which was reviewed by the full department in a one-day retreat session. In attendance at the retreat were all 28 physicians and research members of the department.

A second report recorded the comments and suggestions of the group in its review of the strategic white paper. Six topics were covered in the follow-up report:

* External review.

* Strengths and needs.

* Mission.

* Education issues.

* Medical student education.

* Third-year residency program characteristics.

The group began with discussion of external issues affecting the department, proceeding to strengths, needs analysis, and mission. The closing session of the morning was spent in establishing major educational issues and priorities, with the afternoon devoted to definition of the medical student education program agenda and the design characteristics of a new fellowship year.

As a result of the initial planning and the follow-up retreat, several actions have been taken:

* Initiation of a medical student education program planning process using the Delphi technique to solicit further faculty input.

* First design of the fourth-year residency program, also using the Delphi study method.

* Commitment to development and participation in a Thursday evening seminar series to promote educational activities.

* Creation of a study group on quality assessment.

* Further awards of external funding and active recruitment in molecular neurobiology field.

* Establishment of an administrative/business manager position.

These actions are directly derived from the priorities and strategic directions presented in the original plan. Further planning retreats will focus on clinical services and research, with one-half day devoted to each for full department discussion.

Discussion and Implications

This case study illustrates how one department attempted to create a vision of its most desired future. The process was intellectually rewarding and successful in a wider context of planning in a university setting. The process helped physicians to be proactive through:

* Issue Identification--The group focused on critical issues likely to affect the department's future success and achievements.

* Dialogue--The process fostered a strong dialogue about external and internal changes within and outside the department.

* Education--Members of the faculty and division chiefs were educated about the department's strengths and needs and their personal objectives.

* Psychological Sensitivity-- Department members became psychologically attuned to the internal and external change pressures in medicine and within the organization.

* Interdepartmental Needs--The process identified the need for interdepartmental planning at the medical college level, as the future is a joint venture of several departments.

* Consensus Building--Planning helped to generate consensus on the key issues and the need to focus resources.

* Alternate Visions--The group was forced to think about its future and the alternatives available.

The planning process described above would be useful for other academic departments and for medical professionals in group and individual clinical practice and in HMOs. Physicians not willing to define their own future will find that others have defined it for them. A future defined by others may not be the best future for high-quality care for patients, for medical student education, and for the creation of new knowledge in medicine and the allied sciences.


1. Carroll, L. Alice's Adventures in Wonderland. New York, N.Y.: Macmillan, 1865.

2. Ross, R., and Johns, M. "Changing Environment and the Academic Medical Center: The Johns Hopkins School of Medicine .. Academic Medicine 64( 1): 1-6, Jan. 1989.

3. Heyssel, R. "Changing Environment and the Academic Medical Center: The Johns Hopkins Hospital." Academic Medicine 64(1):7-11, Jan. 1989.

4. Ziegenfuss, J. Designing Organizational Futures: A Systems Approach with Cases for Public and Non-Profit Organizations. Springfield, Ill.: Charles C. Thomas, 1989.

5. Below, P., and others. The Executive Guide to Strategic Planning. San Francisco, Calif.: Jossey-Bass, 1987.

6. Ozbekhan, H. "The Future of Paris: A Systems Study in Strategic Urban Planning." The Philosophical Transactions of the Royal Society of London A287:523-44, 1977.

7. Ackoff, R. Creating the Corporate Future. New York, N.Y.: John Wiley, 1981.

8. Ackoff, R. A Concept of Corporate Planning. New York, N.Y.: John Wiley, 1970.

9. Jordan, B., and Richardson, W. Strategic Planning for Penn State University. University Park, Pa.: Office of the President, Penn State University, 1985.

Julien F. Biebuyck, MB, DPhil, is Eric A. Walker Professor and Chairman, Department of Anesthesia, and Associate Dean for Academic Affairs, pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pa. James T. Ziegenfuss Jr., PhD, is Associate Professor of Management and Health Care Systems, Graduate program in Public Administration, Pennsylvania State University at Harrisburg, and Codirector, Physician Fellowships Program in Quality, Assurance, pennsylvania State University College of Medicine, Hershey.
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Title Annotation:Planning
Author:Ziegenfuss, James T., Jr.
Publication:Physician Executive
Date:Jul 1, 1992
Previous Article:Clinical program renovation management.
Next Article:Certain physician recruitment and retention activities found to be suspect.

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