Worldwide Complexity: Strategic Planning for a Non-Profit Healthcare Organization

A "non-business" plan approach to pursuing an international opportunity

Told by: Paul Plsek

Illustration of:

• emergence (application as a planning principle)
• reflection
• minimum specifications
• metaphor
  
  

The Institute for Healthcare Improvement (IHI) is a non-profit corporation based in Boston. IHI’s mission is to "...help lead the improvement of health care systems, to increase continuously their quality and value..." and it’s vision is to be "...recognized as a premier integrative force..." IHI was founded in 1989 by Donald M. Berwick, M.D. (the current CEO) and has grown in 8 years from a grant-funded group of three people to a self-sustaining organization of about 30 employees with a multi-million dollar annual budget. IHI provides courses in improvement technology, annual conferences, publications, and so-called Breakthrough Series Improvement Projects in which 20+ health care organizations work collaboratively to generate improvements in targeted areas (for example, reducing c-sections).

I have known Don Berwick for many years and personally played an active role in the early work of the Institute. While I am an independent consultant in health care quality management, I have maintained my friendship with Don and an on-going association with the Institute.

While IHI’s mission statement explicitly states "...our initial focus is primarily on the health care systems of the United States and Canada," the Institute has engaged in various efforts in other parts of the world. IHI co-sponsors an annual European Quality Forum along with the British Medical Association. IHI faculty have also conducted courses and provided modest consulting help in the Middle East, Norway, Sweden, and the Netherlands. These efforts have been largely responsive to personal requests for help from individuals who are friends of the organization’s CEO, Don Berwick.

In early 1997, Don and the organization’s COO, Maureen Bisognano (another person I have known for many years), had concluded, along with a few IHI Board members, that there was an opportunity for IHI to expand its work internationally. The thinking at that time was that IHI had a great deal of knowledge for improvement to offer health care organizations in other countries, but that simply responding to requests for help from personal friends was not an effective way to disseminate that knowledge. Preliminary ideas about potentially better ways included setting up branch offices in other countries, establishing franchise agreements with local organizations in other countries, and/or forming a Board of Directors in Europe with the goal of establishing an IHI-like organization there.

Maureen contacted me in February 1997 to ask if I would take on a part-time, senior leadership position at the Institute to lead an expanded international effort. Specifically, the first task was to sort through the variety of options and produce a business plan for the effort. I agreed to take on this work with a commitment of 3-4 days per month over the next three years.

Reflection: The situation is being primarily viewed through a somewhat standard "MBA lens." A successful organization wants to grow and there are a variety of existing business models to choose from. Therefore, a business plan is needed to sort the choices and project revenues and expenses. The story could have proceeded from this point with data collection for an environmental scan and SWOT analysis, leading to quantified benefits and risks associated with the various options.

"Each country is itself a CAS of health care organizations, leaders, regulators, and others. It is hard to plan (in the standard, MBA way) for the evolving needs in the US health care system. This difficulty was multiplied when expanding to multiple countries. Viewing the work through the standard "MBA lens" was not a good way to go. A complexity approach was needed."

On the other hand, when viewed through a "complexity lens" it is clear that there is a massive, multi-level complex adaptive system (CAS) here. Each country is itself a CAS of health care organizations, leaders, regulators, and others. IHI leaders know from their own experience that it is hard to plan (in the standard, MBA way) for the evolving needs in the US health care system. This difficulty would now be multiplied as the thinking expands to multiple countries. Viewing the work at hand through the standard "MBA lens" was not a good way to go. A complexity approach was needed.

At around the time Maureen and I were discussing my potential role at IHI, events were occurring in Sweden that would eventually give us our first "test case" for an IHI international strategy. Citizen disenchantment with long waits for healthcare services had led to a piece of national legislation, called the Dagmar Initiative, that mandated improvements in service; specifically, reductions in waits and delays. The Swedish healthcare service is organized and budgeted at the county level. So, naturally, the mandate to lead the needed improvement effort fell to the Federation of Swedish County Councils (FSCC), a group in Stockholm that has traditionally provided guidance and knowledge resources to the various county councils throughout the country.

Several members of FSCC, notably the Senior Director for Quality, Margareta Palmberg, had attended several improvement courses and conferences sponsored by IHI. Palmberg is also serving as co-chair for the European Quality Forum, co-sponsored by the IHI and the British Medical Journal. Palmberg and her group, who had been advocating improvement methods in Sweden with modest success for several years, suddenly found themselves in the spotlight with a politically-backed mandate to bring about significant improvements. Palmberg e-mailed Don Berwick to tell him what had happened and to ask for help. Don immediately noted that the IHI had just conducted a very successful "Waits and Delays Breakthrough Series (BTS)" that had identified several key "change concepts" that lead to significant reductions in waiting throughout the healthcare organizations that had participated. It seemed natural that this process might be useful to Palmberg and her group.

Again, all of this was happening at about the same time that Maureen was asking me to help develop a business plan for the IHI international effort. The urgency of the need to organize our thinking to serve the Swedes naturally took precedence over the desire to develop a comprehensive business plan for international efforts.

Reflection: It seems natural to interpret these unfolding events through a complexity lens. The events that were unfolding were unpredictable, at least not easily predictable from the IHI’s seat in Boston. Even Palmberg and her team were surprised by how quickly they were cast into the spotlight after years of relatively unrecognized struggle. This is indicative of the emergent, non-linear properties of a CAS.

The details of the Swedish initiative are not important here, except to note the following impressions and outcomes...

• The Swedes agreed to a reasonable financial exchange in return for the rights to use the IHI’s Waits and Delays BTS material to form collaborative improvement groups in Sweden. In other words, this was a good business deal for IHI that never appeared in a formal business plan. This felt good to everyone involved.
  
  
• The Swedes approached their work with great vigor and sense of responsibility. They did not want the IHI to make improvement happen in Sweden for them, they wanted to do it themselves. This also felt good, in that it meant that few IHI resources would be required to support the effort moving forward. This, in turn, meant that we might be able to work many international venues at once without stretching limited resources too thin.
  
  
• While the collaborative is not yet launched at the time of this writing, everyone connected with the IHI who has interacted with the Swedish initiative believes that it will be very successful (based on past experience in launching BTS). It feels like a success, it feels right to everyone.
  
  

While all of this was happening, time was marching forward. The next quarterly meeting of the IHI Board of Directors was coming up in about six weeks. At its previous meeting, the Board had briefly discussed the possibility of an international effort and had agreed to devote much more time to it at the next meeting. This was the discussion that led to my being asked to come on board to help prepare the business plan.

But, clearly, we weren’t going to get a traditional business plan written in such a short period of time. Instead, I suggested that I could put together a sort of "position paper" that would outline some preliminary thinking; enough to feed a meaty discussion at the upcoming board meeting. Maureen thought that this would be fine.

Reflection: Urgency actually works in your favor when you want to use a complexity approach to planning versus a standard MBA/business plan approach. There was no time to do the analysis that goes into a standard business plan. Qualitative, rather than quantitative, analysis is acceptable when time is short. Qualitative analysis is the stuff of the complexity approach; general direction-setting, metaphor, story-telling, learning from action, and so on. In this case, it is fortunate that time pressure came in as it did. But, I guess if I were trying to advocate for a complexity approach to planning, I would be happy to have time pressure (I might even purposefully create it).

Brenda Zimmerman adds her reflection: As I read through this Tale, I started to think about the concept of float. Dee Hock talks about the reduction of float in our world-we no longer have cash float, nor do we have information float. The time between thinking and acting, between conceiving of an idea and putting it into action is shrinking. Hence the notion of strategic (or business) planning as preceding strategic implementation or actions is problematic. Strategies are not formulated to be later implemented in a world where there is no float. Strategies are enacted-thought and action are layered and looped. Mintzberg used the term "strategy formation" to indicate some of this idea. The thoughts that precede action are the filters through which we will judge strategic issues. But even these are shaped by actions and are in their own state of evolution. I think Paul’s approach here is consistent with this line of thinking. He is not abdicating or shirking responsibility by not writing out a business plan. He is recognizing the need to deal with unknowable, emergent futures in a manner consistent with their nature.

The position paper ended up being a four-page document. Page 1 was an overview of the current situation describing the diverse requests for help that IHI had received from all over the world. Page 2 described the "current opportunity;" basically, that there was a natural overlap between the knowledge for improvement that IHI had developed over the years and the emerging tension for change in the health systems of other countries.

Page 3 proposed a set of principles to guide IHI’s work internationally. These were set up in the text as follows: "Reflection on our interactions to date with groups outside North America has already led us to see a set of principles that we might apply to maximize our impact internationally and avoid distractions." These principles included (there were a few others that would only make sense to IHI insiders, I’ve deleted those for brevity here):

• We should build capacity for improvement locally and only work through legitimate, recognized leaders in other countries.
  
  
• We should only work in countries where there is a clear aim to improve.
  
  
• We should only work with groups in other countries that have a legitimate infrastructure to support improvement efforts, the funding sources to see it through, and the experience working as a group to make it happen.
  
  
• Our International collaborations must always be a two-way street of learning.
  
  
• Financial arrangements with international collaborators should always cover IHI costs and return a fair margin to support future efforts.
  
  

Page 4 was a summary and a set of discussion questions for the Board.

Reflection: While I saw the "principles" as a set of "minimum specifications for a CAS," I purposefully avoided using the language of complexity. It wouldn’t have added anything, in my view, and it had a potential downside. I didn’t want to turn people off, nor have the focus of the discussion to be on the pros and cons of a complexity approach. My evolving mental model is: It’s best to just do a complexity approach and then explain it to people after it works (which, of course, allows you to be silent if it flops). The idea here was to state a different approach to business plan development that made sense on its own merits; that it happens to come from a complexity lens is neither here nor there.

Maureen liked the write-up and the Board had a very good discussion based upon it. It helped a lot that this particular Board meeting was in Paris just prior to the European Healthcare Quality Improvement conference that IHI was co-sponsoring with the British Medical Journal. The board members were keenly aware of the diversity in the various healthcare systems around the world and how hard it was for Americans to understand all the details of what was going on in these systems. The notion of approaching the issue of IHI’s international activities with a set of clear principles with which to judge unfolding possibilities, rather than some semi-rigid business plan, was appealing.

The Board tentatively approved continued activity along these lines. They wanted a timeline of activities for the next year or so and a bit more discussion about how exactly we would use these principles to identify and act on opportunities.

Reflection: Luck plays a role in a CAS. The short time frame and the setting in Paris made it easier to gain acceptance for this somewhat unorthodox approach to strategic planning. I did not have to argue against preparing a traditional, analytical business plan. The position paper stood on its own merits as reasonable thinking.

Of course, having avoided openly discussing the issue of an analytical business plan versus an evolving complexity-based approach, there is the danger that at some point someone will say, "OK, so how ya coming on that business plan?" I hope that I am lucky enough to have gotten far enough along the complexity path that I can stop when the question is asked and reveal the new approach as having already been successful in getting us so far. My strategy is to keep doing enough in the language of the old approach to buy time for success to develop. But, who knows?

The principles (minimum specs) create the environment (container) for emergence. But, how would we know when emergence happens? It seemed to me that the next thing to do was to dramatically increase the information flow in this now world-wide CAS. Up to this point, the information flow was primarily through IHI’s CEO, Don Berwick; people in other countries who knew Don would tell him about happenings within their country and ask for IHI help.

Through discussions with various insiders at IHI about the clear need to know more about what was going on around the world, the concept of the "IHI International QI Happenings Data Base" emerged. I generated another "position paper" about this and circulated it among IHI insiders.

The metaphor is that of an Internet web page. The home page would be a map of the world. Click on a country and you can see what’s happening in quality improvement there. The web page would pull together information from three sources: healthcare demographic data bases such as those maintained by the World Health Organization, reviews of articles in the literature written by people outside the US describing quality improvement efforts, and e-mail inputs from people outside the US.

The third source, e-mail inputs from people outside the US, is key. This is where the interaction among agents within this CAS really occurs. The idea, as of this writing, is to send out an e-mail message from Don Berwick, who is quite well known, to a large number of people internationally. The message will briefly describe IHI’s collected knowledge for improvement and then ask for help in compiling an information resource on what is happening in quality improvement around the world (we have a list of specific questions to stimulate thinking).

Based on responses from this initial e-mailing, we hope to establish on-going communications with many people in the healthcare QI field around the world. By making the information public (probably as an actual web site on the Internet) we hope to encourage input, use the dynamic of a public forum to weed out spurious personal opinion from fact, and create a sense of a community working toward a common purpose of improved healthcare. The idea is to gain information, establish mutually-respecting relationships, and build a low-cost information network that is continually updating the picture of quality improvement world wide.

The position paper has stimulated good discussion. Don, Maureen, and several other IHI insiders say, "go for it."

Reflection: The two key insights that I gained by looking at this through a complexity lens were that (1) information flow was critically important and (2) I didn’t have to "control" the information flow. I firmly believe that once the information begins flowing in this huge CAS, it will self organize and allow us to see the emerging opportunities for providing services worldwide (the original goal of the business plan that I still haven’t written). If we don’t get much information back on a particular country, then there is probably not that much interest there and it wouldn’t have been a very good opportunity anyway. The emerging opportunities for successfully providing IHI’s knowledge for improvement will be in countries where the information flow is hot and heavy. We don’t need comprehensive information, or even truthful information. We’ll simply go where the flow is heaviest, engage in more intense dialogue, see what happens, and take steps that seem reasonable as we go.

Of course, the massive e-mail idea might be a flop. If that occurs, we’ll just have to think of something else. Increasing information flow in the CAS will still be the theme, the mechanism for doing this may have to be something else. But the cost of doing it this way is a whole lot less than the cost of setting up a branch office or franchise in another country (two ideas that were originally pondered when the thinking was about developing a classic business plan).

In parallel with all of this, there was still the Board’s request for a timeline and a bit more detail as to how things would go forward. I prepared a two-page addendum to the original position paper. The addendum provided a draft vision statement for the IHI International effort, a one-paragraph summary of the philosophy underlying our next actions, a two-year timeline, and a list of goals two years out.

The one-paragraph summary of philosophy finally begins to reveal the complexity lens. It reads...

"The principles behind our international effort lead us to take an emergent and opportunistic approach to planning, rather than a more traditional goals-and-strategies approach. In other words, in contrast to a business venture where we might set up branch offices in foreign cities and market our products and services, we want instead to become aware of opportunities where conditions are ripe for natural success in the application of knowledge that we already possess. In such a complex adaptive system, we can plan to build sources of information upon which we can act, but we cannot say a priori where that information might eventually lead us to act.

The timeline that follows this provides milestones for the initial construction of the International QI Happenings Data Base and describes a cycle by which IHI will endeavor to identify two countries per year where emerging conditions compare favorably to the principles (minimum specs). This cycle is tied naturally to IHI’s two annual events, the US Forum in December and the European Forum in April; points in time when information flow is particularly heightened and focused. The timeline does not specify exactly where we will form relationships, nor what format those relationships might take; that will emerge from the information flow in the CAS.

Reflection: I am continuing to walk carefully on the line between a traditional approach to planning and a complexity-based approach. I hope that I am indeed near the edge of chaos where creativity occurs. I am at least conscious of wanting to be there. I know from CAS theory that I must provide a container for anxiety. I hope that that is what I am doing; I hope that I am not being seen as being manipulative. Of course, I don’t know if that is how I am being viewed because I am not in the Board meetings to hear and see the discussion. Ah-ha! I need to establish an interaction linkage within this CAS so that I can adapt my behavior if needed. I’ll ask if I can attend the next IHI Board meeting to discuss the international effort.

I am also conscious of the desire to want to keep multiple options/approaches going simultaneously at the fringes of this effort (one of Curt’s emerging principles). I have succeeded thus far in avoiding being clear about whether we are talking about branch offices, franchise agreements, conducting courses, offering assistance on a consulting basis, scheduled conference calls, or whatever. In the end, I hope we can experiment and learn from our experiences with all these forms of interaction.

The IHI Board reviewed the new input (vision, philosophy, timeline, and goals) at its last meeting just a few weeks prior to this writing and again tentatively approved our moving forward as outlined. Don e-mailed me after the meeting and said that the discussion was good, most of the board is very excited about how this is playing out, but two board members are still not completely comfortable. He said that the discomfort was primarily around not being sure how much IHI effort this would consume over time. He did not mention the complex adaptive systems language I inserted in the material, and neither did I in my response back to him. We agreed that I would work with the IHI staff who had been involved in the successful work with Sweden to document how much IHI time and expense went into this.

Reflection: I wonder if the two board members are just uncomfortable with this non-traditional approach to strategic planning. At some point, I will have to deal with this openly. But, for now, there is enough time and support to carry on with the emergent approach. To me, we have "good enough" plans and support.

This story remains a work in progress. I’ll update it as events unfold.

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