Cascading strategy in a large health system: Bridging gaps in hospital alignment through implementation

Abstract

Using any number of open system strategic frameworks, the planning process follows a fairly consistent trajectory: formulation, implementation, and evaluation. Most agree that the formulation and evaluation phases are the most straightforward, yet successful implementation remains elusive. If done thoughtfully, taking advantage of a complementary framework suitable for aligning facility-level initiatives with system priorities presents a feasible opportunity for health systems interested in cascading enterprise-wide strategy successfully. This study provides lessons learned from: (a) consulting literature addressing barriers to implementing strategy effectively, and (b) analyzing insights from a participatory action research study designed to overcome impediments to aligning hospital-level initiatives with enterprise-wide goals and objectives. The analysis provides a baseline examination of hospital alignment efforts that underscores best practices and exposes gaps in both process and evaluation. Results suggest specific tools may function to effectively engage internal stakeholders in a cooperative process capable of yielding preferred strategic outcomes, particularly through the implementation and evaluation phases.

Keywords

case studies change management health service organization qualitative analysis strategic planning

Introduction

Strategic planning guidelines are used by organizations to identify and evaluate factors that promote or impede mission fulfillment and movement toward a desired vision.¹ Many organizations undertake a planning process that follows a standardized trajectory: formulation, implementation, and evaluation.² Scholars and practitioners agree that the formulation phase is the most straightforward, and that the evaluation phase can be reasonably accomplished if stated goals and objectives are observable, measurable, and actionable.^3–6 Implementation, however, poses its own challenges, owing in large part to a lack of functional structure that would aid in aligning lower levels of the organization with plans formulated by leadership.^1,7 Implementation challenges cause many organizations fall short of desired results in spite of efforts to preemptively control anticipated outcomes.⁸ This recurrent theme underscores a persistent shortcoming in current practice: addressing problems symptomatically rather than promoting alignment of strategic problem solving throughout the organization.³

The purpose of this study is to examine the process of implementing a strategic plan across a large health system operating 27 hospitals in nine states and several international locations to determine the extent of organizational alignment with leadership’s stated goals and objectives. Resource dependence theory (RDT) and the resource based view (RBV) guide plan development using the strategy management system (SMS) archetype,⁹ an open systems approach.^2,10,11 Our focus is to interpret responses to system-wide cascading efforts through the implementation phase; thus, the lenses of organizational change and organizational change communication theories are applied during the analysis.^1,12,13

This study adds to our understanding of the challenges faced by a large health system undertaking a strategic planning initiative by summarizing lessons learned from: (a) consulting literature addressing barriers to effectively implementing strategy, and (b) analyzing insights from a pragmatic research study designed to overcome impediments to aligning hospitals’ initiatives with enterprise goals and objectives during implementation. Given acknowledgement from the field that enhanced implementation methods (e.g. communication) are essential to achieve optimal results, further guidance mitigating obstacles through translational research is of particular interest.^1,12,14,15

Background

Change and organizational alignment

Drawing from a 60-year long tradition of organizational change the teleological school of thought holds that a goal or purpose guides the movement of an enterprise toward a desired end.¹ As reflected in health care strategic planning, proponents of teleology view organizational development in a repetitive yet purposeful cycle. According to Van de Ven and Poole,¹ modifications are not prescriptive, nor are the processes rigid; rather, deviations are expected as the entity moves forward in fits and starts toward an envisioned state.¹⁶ One of the major issues lies in aligning various units of the organization (e.g. entities, departments, individuals) to achieve coordination of effort.^1,14,16–19 The process by which to spread and sustain strategic change, particularly within health services organizations, is still not well understood.^1,14 Researchers must disentangle elements of change management and organization development; subsequently, context and confounders are an integral part of such implementation science.¹⁴

Strategy, change, and organizational alignment through communication

RDT is closely related to institutional and open systems theories in strategy formulation and management, as each explains the interplay of external environmental forces on organizational decision-making.^2,7,11 RDT focuses on managers’ efforts to reduce through planning the influence of environmental forces, such as legislation, regulation, and competition, on organization strategy.^2,20,21 The RBV of the firm underscores the importance of antecedent capacities to successful strategic change initiatives, as with tangible or intangible service delivery and support assets: individual competence, technological infrastructure, and/or financial inputs.^22–24 To create value, the organization must also possess the capability to align and leverage such resources so as to exploit the environment in which it operates, thus affecting desired change.^{11,12,18,25–30} Achieving such alignment requires two complementary operating systems designed to (1) flatten the established hierarchy and (2) enhance candor and autonomy among lower-level employees who are willing to shoulder additional, shared responsibility.^10,19,31 Alignment with goals and objectives, occurs via strategic internal communication among executive leaders, managers, and technical experts to overcome resistance and obtain buy-in, a process known as cascading the strategy.^{1,5,6,12,14,18,19,32–37}

The problem

Recent literature describes a tension between day-to-day operational demands and the need to deliver on strategic initiatives, a strategic leap.^5,6,19 Transformation initiatives, as with strategic planning, typically require a shared perceived need for change, a unifying vision, employee commitment to core values, and a culture of mutual trust.^1,25,38 Within the framework, however, lie persistent difficulties in communicating strategy.^1,12,14 Organizational leaders faced with mandates for change often delegate responsibility, and descend securely into an incremental and familiar project management orientation to avoid examining their own assumptions and conclusions about strategic intent.^19,31,39 A significant confounding aspect of incremental strategy deployment is performance measure variation among hospital units belonging to a single system, a trend that defies the central underlying theme of delivering more efficient, effective health care.³

Employing the strategy management system (SMS),⁹ an open systems planning schema aligned with RDT and the RBV, a large United States-based health system set about constructing an enterprise-wide strategic plan that resulted in three major goals, six objectives, and three enabling objectives (see Figure 1). As system leaders embarked on implementation efforts, complications associated with cascading the plan became formidable. Hence, as part of implementation, they sought assistance in evaluating barriers to improving dissemination and enhancing hospital alignment by exploring the following:

Figure 1.

Strategy management system.

What evidence suggests system hospitals understand how align their own initiatives to support the stated goals and objectives of the enterprise’s overarching strategy?

How might a qualitative evaluation be leveraged to examine implementation efforts, thus enhancing the effectiveness of strategy alignment in context?

To address these research questions, we first specify a model of the recommended components of the SMS process resulting from a guided strategic planning evolution. Second, we describe key characteristics of the implementation process, which are intended to identify and align disparate hospital organizations’ initiatives, discretionary projects and programs designed to help the organization achieve its performance targets,⁴⁰ with the enterprise-wide strategic plan. This process is known as cascading the strategy. Third, we analyze the procedures that the organization follows during the cascading phase within the SMS context to determine the appropriateness of alignment efforts. Finally, we compare the various hospitals’ alignment efforts against the enterprise’s strategic goals (see Figure 2). Our analysis highlights both commonalities and differences in enterprise-wide implementation and suggests areas for further improvement.

Figure 2.

Focus on alignment between hospital initiatives and enterprise-wide objectives.

Figure 3.

Phased enterprise strategy evaluation.

Methods

The emphasis of the project was on contextual applied practice and associated support structures.^41–45 We employed a constant comparative approach in this research,^46–48 to include theoretical structuring, data collection, and the production of a chronological summary over a 24-month period. We focused pattern matching⁴⁹ on the a priori coding structure of the objectives and metrics from the enterprise’s strategy map to identify recurring themes and concepts and to seek contradictory evidence associated with implementing the strategy map conceptual model.⁵⁰ Study themes and their interrelationships, which were linked to previous research and relevant theories, comprised the resulting configuration.

Setting

This research derived from a two-year strategic initiative (2012–2014) comprised 27 hospital-level organizations from a single U.S. domestic health system that spans nine states and eight international locations. Participating facilities, positioned in different urban markets, represented a highly vertically integrated system that included health plan and delivery components: primary, secondary, and tertiary care. Long-term and inpatient rehabilitation care were not part of the system’s delivery structure. International facilities were limited to delivering all but emergency services to enrolled beneficiaries of the health plan and were staffed exclusively by U.S. trained providers and locally based English-speaking support personnel. Management positions were also staffed by U.S. trained providers and were supplemented by English-speaking support staff from the local region in each case. Facility management, delivery, and support structures (e.g. policy guidance, personnel management, orientation and training practices, information systems, a single electronic health record, and organizational processes) were homogenous throughout the system, and many staff moved frequently and often between domestic and international operations as part of an institutionalized development structure.

Data collection and participants

Our team pursued a multi-staged process to elicit system-wide strategic alignment efforts. First, we directed a strategic planning activity at a remote system facility to observe the internal and external factors that influenced planning and to identify contextual facilitators and barriers to formulation and implementation efforts. Second, as part of a strategic consulting team that employed the SMS archetype, we developed and implemented semi-structured survey of hospital-level chief executive and chief operating officers from across the enterprise (n = 45) to understand varying approaches to strategic planning, differing performance improvement actions, as well as individual, environmental, and practice characteristics that influenced alignment efforts. Respondents included the following broad categories: research scientists, clinicians, and administrators. Third, we conducted a follow-up survey and assessment of system hospitals (n = 27) to determine the range of SMS initiatives they had undertaken to gage the depth of their understanding for system-wide alignment at the strategy officers’ level and establish a basis for conducting a content analysis of specific initiatives. Finally, we examined internal documents, to include meeting minutes, planning documents, and Lean program initiatives. We also attended informational and planning meetings, scanned both internal and public media, examined of policies and reports, and discussed the SMS process with the system’s planners. Each of the three phases of our analysis served to inform subsequent phases: (1) the case study provided the context for the pilot survey and interviews; (2) the case study, pilot survey, and interviews informed the hospital survey and additional data collection through secondary sources; and (3) all of these efforts were combined to provide a synopsis of alignment activity (see Figure 3)

Analytical approach

Phase 1 – Strategic orientation case study

The hospital-level strategic planning case study (14 days), focused on obtaining qualitative contextual information regarding middle and senior managers’ views regarding external and internal forces affecting their areas of responsibility. Participants engaged in a detailed external analysis that included concentric circles of enterprise actors having the most impact on the organization, to include regional and system-level strategic priorities to provide context for the facility’s role in contributing to the overarching strategy. The team included an external environmental analysis of legislative and political, economic, socio-demographic, technological, and competitive segments. Extending these analyses, we extrapolated five clusters of opportunities and threats: (1) care delivery structure and content; (2) community support and engagement; (3) human capital management; (4) quality and performance; and (5) the competitive environment. It was around these clusters that planners further divided into areas of specialization and considered how clusters aligned with regional and enterprise priorities.

Participants then sought to assess the internal environment associated with the cluster(s) to which they had aligned. Using a RBV of the firm specifically targeting competencies, capabilities, and value creation,^23,24,29 we addressed a series of questions designed to identify strengths and weaknesses in service delivery and support activities. Cluster groups formulated thematic maps aligning opportunities and threats from the external environment with internal strengths and weaknesses. Teams then defined specific issues and supporting measures to create goals, objectives, and action plans. They further aligned each goal with regional and system-level priorities to (1) gauge where their plans supported system priorities and (2) where they needed to close gaps and intensify efforts.

Phase 2 – Pilot questionnaire, interviews, and a review of documents

To evaluate the effectiveness of the cascading process and identify areas to improve communication efforts, we assessed long-tenured executives that had been selected (promoted) within the preceding year to serve the system in fixed terms as chief executive and chief operating officer equivalents (n = 45). Each executive had approximately 15 years of experience within the system’s health services and/or its support organizations, and may or may not have been directly involved in traditional service delivery operations prior to selection. The focus of this phase was on the timing and influence of the enterprise’s new strategic direction. This pilot questionnaire addressed the need to gage stakeholders’ knowledge of strategy-related terminology and organizational alignment efforts explicitly related to the system’s overarching goals and objectives statements (see Table 1).

Phase 3 – Hospital alignment survey

To determine the intensity of diffusion regarding strategic communication plan and the level of alignment by health care delivery organizations with the policy-making body, our team then developed an assessment tool disseminated electronically from system headquarters to strategy officers representing the 27 hospitals in our study (see Table 1 for sample questions). Each respondent was asked to list all of their facility’s current strategic initiatives and to associate each project or program with one or more of the enterprise’s goals and objectives. Respondents also provided free text to explain alignment processes, the day-to-day operational relevance of planning efforts, difficulties they had encountered, and to field requests for additional guidance. The research team assessed responses to determine whether each met the definition of an initiative, as per SMS archetype, and which initiatives they had associated with a single objective. We noted also those that supported multiple objectives. Finally, our team carefully evaluated each response using elements of the Project Management Institute’s (PMI) project management framework, as the framework included the following factors: initiative name, description, anticipated benefits, start/end dates, and metrics.⁵¹ Our aim was to determine which initiative appropriately aligned with the intent behind the enterprise’s stated goals and objectives, more specifically, which included similar terminology (name, description), potentially listed anticipated benefits, and provided defined start and end dates as well as explicit measures.

Analytical summary

This study included a multi-phased approach to data analyses. During the first phase, for which a single hospital was the unit of analysis, data evaluation involved coding staff surveys, interview transcripts, and planning documents using Dedoose^© qualitative software to identify themes across respondents. During the second phase, which included conducting a pilot survey of system-wide hospital leaders, we used three stages of coding. The initial stage involved analyzing text using the survey questions as a coding structure to search for themes and quantify descriptive statistics in whole numbers and percentages. In this phase, our team also employed a constant comparative method of open coding to analyze gaps and identify lessons learned not explicitly covered in the literature. For the third phase, we developed from interviews, surveys, and internal documents, a story from themes that resulted in a set of theoretical propositions.⁵² We established reliability and validity throughout all phases of data collection using data triangulation. The research team, consisting of one onsite author, several system-level strategy officers, and two members of the consulting team, reviewed and discussed independent coding until consensus was reached. We then converged insights among multiple and different sources of information to form themes or categories within this study.^53,54

Findings

Phase 1 – Strategic orientation case study

The intensive planning session produced intelligence concerning: (1) the problems or concerns that consumed a majority of middle and senior managers’ time at the local level; (2) the components of the department’s or service line’s work for which they spent time measuring data and/or would like to understand better through data collection and analysis; (3) aspects of the external environment that impacted the work; (4) areas of responsibility to be discussed formally yet were not currently; (5) critical issues about which they spent considerable time thinking; and (6) how their activities enhanced or impeded the organization’s capability.

The intensive session had an instructive effect on hospital leaders and the research team concurrently. Participants learned to include in their planning efforts the priorities of regional and system actors and to focus less on tactical undertakings of little added value, as with reducing optimization projects (84) to include only those aligned with strategic objectives (12). In addition, they learned to evaluate planning efforts through departmental and individual activities designed to support the facility’s goals and objectives. Executive participants also shared improvements with regional and system leaders: “We used (enterprise-level) materials (e.g. strategy map) as an opening/background to our local efforts. Notably, we also included (regional-level) guidance, which (was) also in alignment”. Consequently, this remote hospital became a standard amongst system facilities for strategic alignment originating from the base of the pyramid. The team found that the experience yielded valuable insights into understanding local planning, communication across the enterprise, and the value of cultivating individual ownership in the process. Such insights became useful in both pilot and hospital alignment assessments, as the team adopted a facility perspective in cascading efforts.

Phase 2: Pilot questionnaire

Of 45 executive respondents, 19 identified their organization as a hospital (42%), as the group derived from the system’s service and support settings. All (100%) respondents correctly listed the enterprise’s three overarching goals, likely because content related to such goals had been delivered on-site during the course of the executive orientation session through which the assessment was conducted. Of the 19 respondents, only three (15.8%) indicated they had completed strategic planning less than three months prior to the assessment; another 12 (63.2%) completed planning between three and six months prior. Only two of 19 respondents completed planning between six and 12 months prior. One (5.3%) of 19 respondents indicated they had completed planning 18 months earlier, and the final respondent left the question blank (missing data). Of 19 respondents, 15 (78.9%) either agreed or strongly agreed that the enterprise-wide strategic plan had heavily influenced the organization’s most recent strategic planning effort. Only three were neutral or slightly disagreed (15.8%), with one outlier strongly disagreeing. Interestingly, the respondent who strongly disagreed represented the enterprises’ flagship facility.

To assess the level of understanding for alignment with the enterprise’ strategic plan, respondents were asked a follow-up question: How did (the enterprise’s) strategic plan influence the (hospital unit’s) most recent strategic plan? Of 19 respondents, only eight (42.1%) completed the question. Several respondents alluded to the enterprise-wide plan using incorrect terminology, incorrect in that it did not match the terminology proposed by the SMS framework. Specifically, there was confusion about the use of the terms: pillars, goals, objectives, and initiatives. Two executives responded: “It gave the hospital the base/guidelines on which we built the hospital’s goals/objectives”, and “We reviewed the guidance completed our SWOT analysis, and aligned our objectives with the strategic goals”. Some appeared to have relied on previous experiences with planning to create their own goals and objectives and/or to state simply that the organization’s plan was tied “directly” to the enterprise. Only one respondent used the appropriate terminology of “initiative”, which was intended by strategy formulators at the enterprise level: “(It) established guiding principles for the hospital to base strategic initiatives upon.” Two more endeavored to align hospital strategy with regional planning, an intermediary between hospitals and the enterprise headquarters; both of these respondents derived from the same region, and one represented the organization with which we had conducted the intensive strategic planning initiative outlined above.

To understand how hospital leaders used their strategic plans to guide operations, set targets, and evaluate results, we asked (1) how often organizational executives referred to the strategic plan when making decisions, and (2) how they personally made operational decisions based on alignment with the stated strategy components (goals, objectives, or initiatives, as they understood them). A large majority, 15 of 19 respondents (78.9%), stated that they personally either very frequently or frequently did so. A minority, three of 19 (15.7%), responded that they rarely or never used the plan for decision-making. To drive further down the organizational hierarchy, therefore, we asked two follow-up questions to determine whether they believed lower-level employees could (1) recall major components of the organization’s strategic plan, and (2) understood how their work directly supported a major goal or objective (using their terminology). Of 19 respondents, eight (42.1%) indicated that they disagreed or strongly disagreed with both questions, another seven (36.8%) were neutral in both instances, and four (21.0%) agreed, with only one indicating they strongly agreed. A middle manager in attendance offered: “(We need) more communication with the hospital’s (executive leadership)”, while a hospital CEO provided an alternate perspective stating, “…we need more positive communication (with) the lower level workers, which is on the shoulders of our Directors”. In addition, a third executive provided the team with a suggestion: “Our (Enterprise CEO) is a talented speaker. Have him do a video to all levels (maybe different audiences) explaining how our staff can assist in reaching the goals”. Conflicting results, therefore, led us to believe internal communication about implementation efforts was not optimal, which required additional investigation.

Phase 2 – Hospital alignment survey assessment

Respondents reported 313 hospital initiatives, of which the team identified 171 as primary. Primary initiatives were defined as those that included text descriptions and metrics most closely associated with one or more objectives from the systems’ strategy map (see Table 2). Problematic was the practice of overlapping initiative alignment, which created a difference between the total initiatives reported and those identified as primary. This occurred when respondents associated any one initiative with two or more objectives, which may have indicated cross-functionality and/or an attempt by respondents to demonstrate alignment with all or many objectives. The team also noted here a recurrent problem of retrofitting hospital initiatives so as to align with the enterprise-wide strategy map rather than prospectively structuring a process of associations thoughtfully aligned with the current strategic direction. Evidence further suggested a misunderstanding between operational (or day-to-day) activities and strategic initiatives, as was noted by 66 instances of the use of “ongoing” to describe metrics. Overall, data indicated that there might have been confusion between understanding alignment and the use of objective measures to indicate actual alignment. Nonetheless, the team endeavored to document alignment as accurately as possible using metrics and descriptions, triangulating coding interpretations, discussing results, and in a few instances, calling respondents for clarification.

Table 1.

Examples of pilot and survey assessment interview questions.

Topic	Question examples
Facility planning experience	How long ago did your facility complete its most recent Strategic/Executive Planning evolution (months)?
	Assessing agreement: (The Enterprise’s) Strategic Plan heavily influenced the facility’s most recent Strategic Planning effort (Likert scale).
	If applicable, explain how (The Enterprise’s) Strategic Plan influenced the focus of the facility’s most recent Strategic/Executive Planning evolution (open).
Facility alignment with strategy	How frequently does the facility refer to its Strategic Plan when making decisions (Likert scale)?
	How frequently do you base work-related decisions upon how those decisions influence specific objectives of the Strategic Plan (Likert scale)?
	If applicable, please explain how facility leadership uses its Strategic Plan in making day-to-day operational decisions (open).
Integrating strategy at the local level	Assessing agreement: Facility employees at all levels can easily recall and discuss major elements of the Strategic Plan (Likert scale).
	Facility employees at all levels clearly understand how their work directly supports a specific goal or objective of the Strategic Plan (Likert scale).
	If applicable, please explain how you believe facility staff bases work-related decisions upon how those decisions influence specific initiatives contained within the Strategic Plan (open).
Improvement efforts	What would help you to understand and better implement The Enterprise’s Strategic Plan within your facility? Please share any additional comments or questions (open).
	If applicable, what difficulties did you experience, (and/or do you continue to experience) with regard to engaging in the most recent Strategic Planning evolution (open)?

Table 2.

Alignment of initiatives to goals and objectives within the strategy map.

Goal	Objective	Initiatives primarily aligned to objective	Total initiatives aligned to objective	Hospital organizations aligned	Total initiatives
Quality Management	QM1	35	55	24
	QM2	47	54	27	QM: 166
	QM3	20	57	25
Human Capital Management	HCM1	34	41	26
	HCM2	6	8	7	HCM: 69
	HCM3	6	20	11
Competitive Environment	CE1	15	32	19
	CE2	4	17	9	CE: 66
	CE3	4	17	10
“Other”	Other	0	12	7	Other: 12
Total		171	313		313

Overall, the highest reported total alignment occurred with all objectives under Goal 1, defined as Quality Enhancement (Objectives coded as: QM1, QM2, and QM3), then Goal 2, expressed as Human Capital Management, Objective 1 (Objective 1 coded as: HCM1), followed by Goal 3, the Competitive Environment, Objective 1 only (Objective 1 coded as CE1). Results also indicated that several hospital organizations (n = 7) had undertaken initiatives that respondents reported did not align with any portion of the strategy map; thus, initiatives were coded as Other, none of which included primary alignment with defined objectives. (Note: Titles reflect our interpretations. See Table 2.)

Quality management

The Goal of Quality Management accounted for 166 total initiatives, as all three objectives represented the highest total initiative alignment: QM1, QM2, and QM3. A total of 55 initiatives were reported as aligned with QM1, with 35 identified as primary. Hence, QM1 represented the second highest score in terms of alignment. QM2 represented the third largest number of total alignment with 54 initiatives aligned; yet, QM2 appeared to have the strongest support following a review of metrics to determine primary alignment, with 47 initiatives aligned. Incidentally, QM3 embodied peak reported alignment, with 57 total initiatives reported as aligned; yet, only 20 were primarily aligned. The team’s interpretation of reported alignment was that hospital organizations appeared to more closely associate with QM3, but in reality responses indicated that they tended to align metrics with QM2 more often. Furthermore, all (100% of) respondents reported alignment with objective QM2, which was not the case among others.

Human capital management

The Goal of Human Capital Management accounted for 69 total initiatives, as all three objectives represented the second highest total initiative alignment: HCM1, HCM2, and HCM3. It is important to note that all but one respondent (n = 26) reported initiatives associated with HCM1, which indicated the strongest organizational alignment. A total of 41 initiatives were reported as aligned, from which 34 included metrics primarily supporting alignment. The lowest level of total alignment occurred within Objective HCM2; with only eight (n = 8) initiatives reported as aligned, six (n = 6) identified as primarily aligned, and with regard to hospital organizations reporting alignment (n = 7). Respondents from 11 organizations reported alignment of 20 initiatives with HCM3; however, only six (n = 6) were coded as primarily aligned.

Competitive environment

Respondents reported the lowest levels of alignment with the goal representing the Competitive Environment, with total alignment of 66 initiatives associated with objectives CE1, CE2, and CE3. From the hospitals’ perspective, alignment with CE1 occurred most often 19 organizations reporting 32 initiatives aligned, but with only 15 coded as primary. Respondents least associated with CE2, as nine (n = 9) organizations reported alignment of 17 initiatives, four (n = 4) of which were coded as primary. With regard to CE3, 10 (n = 10) organizations reported alignment of 17 initiatives, with only four (n = 4) coded as primary.

Other

Results revealed at total of seven (n = 7) organizations aligned 12 initiatives with the Goal coded as Other. Initiatives within this category were developed at the local (hospital) level, and appeared to address community and/or environmental needs associated with a given location. Enterprise-level guidance allowed for the development of such initiatives, which were to be reported yet separate from specific goal alignment. Evidence suggests that only 26% of hospitals had adopted such activities.

Summative results

In summary, results indicated that facilities most often aligned initiatives with each objective under the Quality Management goal (QM1, QM2, and QM3), suggesting effective use of operational definitions and associated metrics under this section. In addition, when the research team engaged in discerning primary alignment using metrics, we identified areas of greatest alignment within one objective associated with each of the three goals: QM2 (n = 47), HCM1 (n = 34), and CE1 (n = 15). Results, therefore, pointed to areas of utmost agreement between the system and its 27 facilities under each goal. Our results also revealed areas of least alignment, particularly within the Competitive Environment (CE2 and CE3, n = 4) followed by Human Capital Management (HCM2 and HCM3, n = 6). Such outcomes indicated either a need to enhance facility education and outreach and/or a requirement to reexamine the strategy framework at the system level.

Limitations

Participatory action research^55,56 in conducting a comparative analysis served to inform our examination of hospital alignment efforts, thus discerning the effectiveness of strategy alignment in context. The limited the number of respondent hospitals in our convenience sample (n = 27) were drawn solely from facilities associated with a single health care system. To address concerns of bias, we were purposeful in structuring analyses to obtain conflicting information where relevant, as with open-ended questioning, ensured diversity in respondent characteristics, and asked hospitals to provide unadulterated material about alignment initiatives. Multiple members of our team, who also represented clinical and nonclinical staff, coded and analyzed data over a 24-month period, which were reviewed by an external qualitative researcher. We resolved differing interpretations through consensus and/or additional data collection. We invite future research of implementation endeavors to assess the boundaries of our findings.

Discussion

Understanding priorities and strategic alignment

Our analyses reveal several broad themes influence strategic alignment of hospital units with the enterprise organization, and further provide a detailed understanding of these influences. Study participants underscore four key elements hinder their ability to align with strategic priorities set by higher headquarters under the SMS. First, hospital-based respondents demonstrate a lack of understanding regarding the strategic framework and associated terminology, particularly because key terms do not apply at the hospital level (goals and objectives versus initiatives), and hospital representatives are not involved with the planning process at the system level. Second, hospital-based respondents’ interpretations of strategic priorities vary broadly, with some in alignment and others focusing to a greater extent on tactical or day-to-day activities of little strategic value. Third, while many can appreciate hospitals’ roles in supplementing the SMS on a broad scale, their combined strategic posture is reactionary at best, as evidenced by the widespread practice of retrofitting ongoing initiatives in the absence of well-conceptualized strategic assessments to support or refute their inclusion. Lastly, most difficult for respondents is how to express accountability for results at all levels of the organization.

Enhancing strategy alignment in context

This research demonstrates how strategic implementation succeeds or fails based upon the clarity of the message and efficacy of communication, which requires a framework of messaging, tailored to the context from which the target audience derives. A case in point is highlighted by results that indicate hospital strategic alignment and evaluation efforts often reflect business-as-usual practices retrofitted for the strategy context. This means specifically that initiatives are not necessarily formed proactively in response to changes in strategic direction from higher headquarters, which are cascaded down through the organization. Rather, they represent changes in labeling. Findings further suggest that the enterprise must actively seek to verify and understand trends about strategic implementation at the hospital level for the purpose of developing thorough communication plans. This is particularly germane if the enterprise wishes to effectively engage its system of internal stakeholders in a cooperative strategic planning process that yields preferred strategic outcomes. As such, they must include in such communication plans targeted training and education schemes designed to bolster strategic alignment and enhance evaluation efforts.

Evidence-based implications for practice

Deliberate organizational change, to include healthcare strategic planning, is repetitive yet purposeful cycle propelled by stated goals that move an enterprise toward a desired end.¹ Our results indicate that describing the nature of variation among hospital initiatives can guide alignment efforts to achieve coordinated implementation across the enterprise.¹⁷ The early launch phase, represented here by cascading the strategy, is the point at which planners must recruit change agents and marshal employee support through effective communication.^18,25 Our findings indicate that baseline analyses of current projects serve to define the scope of hospital initiatives prior to implementation and specify qualitatively (through content analysis) and quantitatively (use of explicit metrics) the degree of organizational alignment. We identify areas of greatest agreement across hospitals and with the overarching enterprise. We also highlight areas less emphasized at the hospital level. We posit, therefore, that our analysis underscores a point of action to leverage communication activities that enhance candor and shared responsibility.^19,31 Accelerating the cascading process in the healthcare enterprise requires the ability to communicate the necessity and plan for specific change^18,19,35 and to provide meaningful feedback about the nature and course of the precise adjustments necessary to align hospitals with enterprise-wide goals and objectives.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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