The Institute of Medicine (IOM) report, Academic Health Centers—Leading Change in the 21st Century, calls for a radical transformation in the way academic health centers (AHCs) establish their clinical care, education, and research priorities.1 The IOM underscores the growing interdependency of academic units and the need for effective collaboration and partnerships to achieve the increasingly complex mandates of academic health centers. Academic leaders face the challenge of forging a clear vision for their department or division in this complex environment with multiple potential stakeholders and partners including patients, communities, government, industry, and academic units within their own university. A formal strategic planning process can help create a clear vision, taking advantage of potential collaborations between the stakeholders.
In the past at the University of Toronto Faculty of Medicine, clinical departments typically developed plans for their academic unit by setting research and teaching goals for the upcoming five years. Usually, the members of the unit contributed to the development of those goals in an informal process led by a new leader. This informal method often lacked the perspectives necessary to embed the plan in the broader context of the faculty of medicine, the university, and the larger community. The opportunities for developing excellence in academic endeavors by collaborating across academic units and with community or government were not obvious. Further, this informal planning process often resulted in faculty members continuing what they were already doing well without fully exploring what the individuals and academic unit could potentially achieve with a broader, more collaborative approach to achieving academic excellence.
Successful collaborations are most easily achieved when both parties are clear about their respective visions and can recognize and take advantage of the common ground between them. Effective strategic planning offers a mechanism for faculty members in a department to clarify their vision and to test potential partnerships. Outcomes of strategic planning include a clear mandate and direction, articulation of specific long- and short-term goals, benchmarks for measuring progress, and the potential for members from across the organization to actively participate in shaping its future.
Our objective is to demonstrate the process of strategic planning, using the experience at the Department of Medicine at the University of Toronto Faculty of Medicine, a major AHC, as an example. The process of involving multiple perspectives from the department faculty members, colleagues across the faculty of medicine and the university, and targeted stakeholders allowed the opportunity to shape collaborative academic efforts. In fact, the title of the final plan was Collaborating for Excellence. The process we describe can be applied to any academic unit, including a traditional section or division, department, faculty, or a more programmatic unit.
The Department of Medicine of the University of Toronto is one of the oldest and largest in North America, dating back to the establishment of the school of medicine in 1843. The department houses over 480 full-time faculty members who are distributed among five major teaching hospitals and the university campus. The department supports approximately 580 postgraduate trainees in internal medicine, including 166 in the core internal medicine program, 195 subspecialty trainees, and 220 fellows. The department faculty members play major roles in the undergraduate, postgraduate, graduate, and continuing education programs of the department and university. The department research grants total approximately $105 million per year in operating funds (Canadian grants do not include any salary support). It is the largest department of medicine in Canada, and in 2004, external reviewers rated the department in the top 10 public institution departments in North America.
Building Our Department's Strategic Plan
In July 2004, the newly appointed chair initiated a planning process for the department. This was the first comprehensive strategic plan undertaken by the department. As part of the process, more than 300 faculty, staff, students, and residents, as well as other key stakeholders, provided insights into the internal and external environment that were likely to have the greatest impact on the organization and practice of medicine in the future. The process also provided the opportunity to reflect on the many achievements of the department and to share ideas about how best to respond to current and future challenges. This broad input, combined with the leadership of the strategic planning committee, culminated in the development of a new strategic vision and clear plan of action for the department to achieve its vision during the next five years.
Start-up is one of the most important steps in the planning process. An experienced external consultant, one of the authors (H.A.), was retained to guide the process. A steering committee was established with a clear mandate, and, as a first step, it developed a set of principles to guide the planning process. During the start-up phase, agreement is reached on timelines, key milestones, and the scope of the fact-finding and consultation process.
The steering committee itself presents an important opportunity. Typically, the leader of the academic unit will chair the strategic planning committee, particularly if he or she is a new leader. Where there is an existing executive committee or council, comprising leaders of key portfolios (e.g., undergraduate medical education, postgraduate education, research), this committee may assume oversight of the process. However, the academic leader may use this opportunity to go beyond the traditional executive committee and either create a new steering committee or augment the executive committee with individuals who bring new and different perspectives to the planning table. In general, the steering committee should include key leaders in the department, leaders of a few targeted potential collaborative units outside the department, and several individuals who are likely to play a key role in the future implementation of the plan.
In the case of the department of medicine, the chair convened a “special purpose” strategic planning committee and used the opportunity to engage a mix of junior and senior faculty members (both MD and PhD) within the department, an associate dean who brought the faculty of medicine perspective, the leader of a key collaborative research institute, and a representative from a community affiliated hospital, a constituency becoming increasingly important to the department. The business manager of the department was also a member, which facilitated access to relevant planning data and ensured that there was always someone mindful of the resource implications of the recommendations and proposed strategic initiatives. In addition to this mix of committee members bringing a breadth of expertise to the planning table, early in the process, the department succeeded in engaging a group of physicians with the potential to lead new initiatives. This commitment proved to be invaluable throughout the project and to the future implementation of the plan.
Committing to planning principles
It is useful to establish a set of planning principles to guide the planning process. These principles confirm the scope of the process and articulate important shared values. The articulation of values communicates how the planning process will be conducted and, ultimately, the manner in which the department intends to achieve its vision and mission. In the first meeting of the strategic planning committee, the department of medicine confirmed 10 planning principles to guide the process (List 1). For example, one of the principles was to “be open and consultative, inviting input, debate and dialogue from all faculty members and provide open communications as to the progress of the process.” This principle guided the process used in the planning and in the dissemination and mandated using specific strategies to achieve this goal.
Establishing the work plan
In our experience, AHCs are eager to conduct a strategic planning process efficiently, completing the task in a timely fashion. A streamlined work plan, with clear timelines and deliverables, needs to be agreed on at the start of the process. Although there is always the need to be flexible, a comprehensive, highly consultative planning process, such as the one we describe here, can generally be accomplished within six to nine months.2Figure 1 outlines the phases of a typical strategic plan. Frequent complaints about strategic planning processes are that they take too long, there are too many meetings, too much time is spent on the “vision thing,” and not enough time is devoted to developing the implementation strategies to actually achieve the vision. In this case, the strategic planning committee met five times, participated in a full-day planning retreat, and oversaw a process that engaged several hundred faculty members and trainees. The project was completed within seven months, with ample lead time to prepare for implementation in the new academic year. This was a relatively ambitious timeline that required a high level of priority for the chair and the department staff.
Understanding the environment
The fact-finding and consultation phase is the most variable step in the planning process. The scope and comprehensiveness of this phase is generally dependent on the timelines and budget for the project. However, it is critically important to include the perspectives of both members of the department (trainees and faculty members) and of the other academic units that may potentially collaborate with the department. For example, the consultation process of the department should include other department chairs in the faculty of medicine, chairs of other departments in the university, hospital CEOs, local health policy makers, or other leaders. New potential collaborations are developed by understanding the needs of these stakeholders and the opportunity to advance the goals of these stakeholders in concert with the department. The consultation process provides an opportunity for partner engagement and the potential to explore common ground between these separate units or organizations.
There are a variety of effective ways to get input from stakeholders, including Web-based surveys, in-person and telephone interviews, focus groups, or time-limited task forces charged with developing background papers on specific issues that have been identified as important areas for the future of the organization. The use of multiple methods allows faculty members to choose to participate in a variety of settings or formats. The focus groups, facilitated by the consultant, were designed to gather input from diverse stakeholders and to engage as many faculty members as possible in the process. Key questions for the focus group were customized to the focus group members by the consultant. For example, one focus group was dedicated to medical students and trainees and yielded important recommendations to enhance the community-based and ambulatory care components of training. The core themes from all of the focus groups, interviews, and surveys were abstracted and synthesized by the consultant.
The department of medicine used a mix of these tools to capture both the breadth and depth of issues and to tap into sources and people not often called on in these processes. In the initial planning, the chair of the department held grand rounds at each of the five major affiliated hospitals. She posed three questions during the grand rounds and facilitated a discussion with the audience for 15 minutes on each one. The questions were, What are the key changes occurring in medicine and health care that we need to consider as a department? What are our opportunities to significantly advance our academic mission during the next 10 years? How do you want the department to communicate with you? All faculty members were also invited to participate in the planning process through an online survey, with responses going to an objective third party (external consultant) for collation. Targeted focus groups were conducted with over a dozen different groups including researchers, teachers, trainees, and community faculty, to stimulate novel ideas and to determine key issues and opportunities facing the department.
Pulling it all together
It is not unusual to spend too much time in the fact-finding phase collecting one more report, holding one more focus group, or calling one more expert for his or her insights. However, there comes a time in all planning processes when the themes begin to emerge, when a number of strong hypotheses need to be tested, and when the input that has been gathered from a variety of sources needs to be organized into a useful framework. Several analytic frameworks are commonly used, for example, a SWOT analysis (strengths, weaknesses, opportunities, and threats) or an assessment of an organization's situation in terms of assets, opportunities, and vulnerabilities.2 These analyses provide a realistic starting point for shaping the vision and generating the strategic directions and goals to achieve that vision.
Shaping the vision
A vision statement has three components: the vision, mission, and values. The vision—at once compelling and bold—is the ultimate outcome to which the unit aspires. It describes an envisioned future and what success will look like. Jim Collins,3,4 author of Built to Last and Good to Great, calls it your “big, hairy audacious goal” (BHAG), a forceful statement of what an organization wants to become or achieve that reflects a fact-based view of the future that is demanding but achievable. The vision often describes an inspiring new reality, generating excitement and motivating change. Unlike a mission or core purpose, which can never truly be completed, a vision has a specific time horizon and, once achieved, will be replaced by another “big goal” that will serve to inspire and drive the organization forward.
The mission captures the organization's core purpose and answers four basic questions: who you are, what you do, who you do it for, and why you do it. An effective mission statement reflects people's idealistic motivations for doing the organization's work and is expected to endure over time.4 Underpinning the vision and mission are core values—the set of beliefs on which organizational decisions are made and actions are taken. Although the vision and mission set the strategic directions of an organization, the values shape the organization's culture and determine the manner in which the unit will fulfill its mandate and achieve its goals.
In creating its vision statement, the department of medicine began with the faculty of medicine vision, with a view to aligning itself to the broader organizational vision. Although overall, the faculty's statement worked well as a guide, the department chose to refine the vision, mission, and values to more fully reflect its own aspirations and culture. In particular, the department debated the faculty's list of values and ended up with a shortened, more focused set of values that emphasized critical values of collaboration, self-evaluation, and accountability. Today, this vision statement is embedded in the department's monthly newsletter, is revisited regularly in monthly meetings of the implementation committee, and is the cornerstone of every proposal or document emanating from the department (List 2).
Testing the strategic directions
A midcourse planning retreat is an efficient way to bring faculty and key stakeholders together to confirm the evolving vision statement and to test the strategic directions and goals that have emerged from the fact-finding process. Given that many faculty have been consulted early in the process, most are prepared to move to the next stage of establishing priorities and generating implementation strategies to support these priorities. Actively involving faculty members from the outset facilitates implementation, because they are likely to feel invested in the success of a plan that they helped to shape. Furthermore, if the strategic plan seems familiar to the faculty members, it signals that their input was valued and used productively. Ultimately, the contents of a strategic plan should not be a surprise to faculty members. They should have a chance to “get their fingerprints all over it” before it is finalized.
To optimize the efficiency of the planning retreat, the strategic planning committee typically generates draft strategic directions and goals that can be debated and discussed at the retreat. The committee should be challenged to keep the strategic directions to a minimum and memorable set—perhaps four to six overarching directions. In our case, the six key strategic directions were the following: (1) achieve greater integration across the department and beyond traditional disciplinary boundaries, (2) enhance the attractiveness, productivity, and impact of research, (3) transform and enrich teaching programs, (4) advance quality of care and develop performance measures in this area, (5) retain, attract, and nurture faculty, and (6) reinforce the funding and infrastructure base. For each area, it is critical to establish long-term (five year) and targeted short-term (one year) goals with clear performance measures and expected outcomes. Identifying “quick wins” for the first year of the plan encourages faculty commitment and the ultimate success of the plan. During the retreat, faculty members can provide feedback on short- and long-term priorities for implementation. The group can reach agreement on these goals and can brainstorm potential actions and implementation strategies to achieve these goals.
The department of medicine invited over 100 faculty, trainees, and key external stakeholders to a one-day planning retreat. The CEOs of six of the major area hospitals, leaders of key research institutes, and several regional government agencies attended. A few local and international experts were invited as speakers and panelists to provide perspectives on the broader context in which this future planning was taking place. Speakers also challenged the group to recognize the gaps between the present department and the potential for the future. For example, the president of the university and former dean of medicine at University of Toronto, as well as a chair of medicine from a prestigious U.S. academic center, shared their perspectives. In addition, several speakers were selected to be provocative and to challenge the status quo of the department by presenting future trends in medicine. Invited talks were short, allowing a significant amount of time for discussion and interaction.
For many organizations, the last step of the strategic planning process is finalizing the written plan. Painstaking attention is paid to editing, formatting, and producing the final document. Often, a communication strategy is developed in this final phase, targeting the various audiences and delivery channels for distribution of the plan. However, the most critical final step in strategic planning is positioning the plan for execution—that is, ensuring readiness to implement the plan. To make sure that this step was not overlooked, the department of medicine committee included recommendations in the strategic plan to establish an implementation committee. Terms of reference were outlined, including the responsibility for developing a dissemination and communication strategy, and compiling overall performance measures, timelines, and resource requirements for each of the plan's six strategic directions and for monitoring progress toward goals. Accountability for fulfilling the goals for each of the strategic directions was assigned to six lead faculty members who were appointed to the implementation committee. A project manager was hired to support faculty in fulfilling these new roles.
The strategic planning committee also identified year one implementation priorities, which immediately put the plan into action, targeting “low-hanging fruit” or foundational work that needed to begin within the first 6 to 12 months of the new plan. This created momentum and sent an important signal that the strategic plan would indeed be the road map for the next five years.
Promoting the plan
Critical to the success of a plan is a very active role for the leader in promoting the plan, engaging faculty in participating in specific tasks, and regularly updating the faculty, dean, and key stakeholders. The department of medicine plan, Collaborating for Excellence, was communicated broadly. It was posted on the department Web site, and each full-time faculty member was given a “glossy print” copy of the plan. As part of the communications strategy, target audiences were sent an executive summary of the plan. New recruits are all given a copy of the strategic plan and provided with the context in which it was created and an update on progress toward goals.
In part symbolic and in part functional, a massive white board now hangs in the department conference room, with the six strategic directions boldly inscribed across the top, accompanied by corresponding long-term goals. Below each of the six long-term goals, the short-term goals are listed on a removable panel. The short-term goals can be checked off when they are completed, and the panel can be exchanged for the next set of action items. Checking off completion of the tasks is handled ceremoniously at meetings of the department executive committee, reinforcing the importance of undertaking and completing these actions.
Subsequent to the creation of the department plan, each of the 18 divisions engaged in developing their own strategic plans, which are intended to align with the department's vision and six key strategic priorities. In an effort to enable this process, the chair has offered consulting resources to division directors and supported divisional planning retreats, adding further depth and breadth to the implementation strategies originally conceived at the departmental level. Extending the process to the divisions reinforces the theme of collaboration and adds momentum to an action plan that is steadily driving forward. As an incentive to the divisions, the chair provides additional financial resources to the divisions which have completed and are implementing their plans. Division chiefs are evaluated annually, partly on the basis of the progress of their plans.
How are we doing?
Objective evidence of success is indicated by the number of goals that have been completed and checked off on the white board in the conference room. This is a clear, demonstrable indicator of progress for the faculty and trainees who use the conference room on a regular basis. The department regularly publishes updates in the newsletter and on the Web site. Grand rounds (now telecommunicated citywide as a result of the plan) provide a yearly “state of the union” address, presented by the implementation leaders. External partners provide informal feedback about the department's progress and initiate new collaborative efforts that are based on early successful programs and that indicate the department's willingness to work together. As success becomes more evident, faculty members are stepping forward to become involved in implementing the plan.
Challenges and Lessons Learned
Although this strategic planning process resulted in a strong vision and clear strategic directions for the department, the process and implementation have their inherent challenges. There are a number of important lessons that have been learned.
- Achieving meaningful engagement is not easy. The department of medicine has nearly 500 full-time faculty members. Although many were engaged in some capacity, there were inevitably some people who were either not reached or who chose not to participate in any one of the number of forums offered throughout the process. The key is to engage as many formal and informal leaders as possible, to create momentum and enthusiasm for the vision. This helps to prevent the skeptics or those who are apathetic from derailing the process.
- Balance a lofty vision with a doable plan. In a large, distributed department or organization, there is enormous power in articulating an inspired vision that creates a rallying point for faculty members. However, equally important to success are identifying discrete and achievable goals, and outlining clear action steps to meet these goals. There is an inherent tension between creating a comprehensive, inspiring vision and making the plan feasible in a reasonable time frame.
- Sustaining the energy through implementation. The department strategic plan has a five-year time horizon that is typical for strategic plans, which often range between three and five years. It is critical to avoid the tendency to move on to something new once the plan has been produced. The challenge is to embed the strategic plan into the agenda of all of the work of the department at the executive and divisional levels. Leaders must use and seek out opportunities to promote the plan, showcase achievements against the goals, and continue to engage new faculty and staff to undertake opportunities and challenges set out in the plan. Cascading the planning down to the divisional levels has brought a new energy to the department strategic plan and has generated unique, innovative approaches to addressing the six strategic directions.
- Supporting faculty leaders with sufficient resources to implement the plan. Although the department was quick to identify theme leaders and assign accountability for each of the strategic directions, in some cases we lagged behind in securing appropriate resources to support the implementation of strategic initiatives. This cost us time and resulted in some frustration as leaders created plans but staff support was inadequate to implement the specific actions. An important lesson is to work with theme leaders to assess the resource implications of short-term implementation priorities and to ensure that the necessary staff and other infrastructure are available when leaders are ready to get going. Few faculty members sought additional funding or salary support for taking on new roles related to the strategic plan, and most identified administrative or technical support as key enablers.
- Measuring the impact of the plan. An early assignment of all theme leaders was to develop performance measures for their respective strategic directions. Some areas are easier than others, such as evaluating the increase in research productivity or growth in revenue through an increase in the number of funded chairs. However, finding appropriate indicators for and measuring the impact of enhanced integration and collaboration presents greater challenges. It would have been helpful to spend more time during the planning process to express the expected outcome of each of these strategic directions and to determine how we would measure the overall impact of the strategic plan. This remains a priority and an ongoing challenge for the department's implementation committee.
Successful businesses have incorporated formal strategic planning into their usual work process. These formal techniques are highly applicable to AHCs, particularly as they face the challenges posed by the IOM in Leading Change in the 21st Century.1,5–7 We believe that the process has significantly enhanced our academic productivity in many areas and has led to several major new initiatives that would likely not have developed otherwise. For example, the department plan recognized the need for a common Web-based curriculum vitae that all faculty members can use and that can produce aggregate reports on a variety of academic activities. The department found the appropriate software for this task and partnered with the affiliated hospitals and with the medical school to pilot this product for the whole faculty of medicine.
A large academic department located at multiple hospitals has the challenge of forging new directions with the broad support of many partners and stakeholders. Formal strategic planning can facilitate this process and build successful collaboration in a variety of academic units.
The authors thank Amit Shah for his help with gathering literature and editing the manuscript.