Discussions I've had recently with health care leaders seeking advice on raising HCAHP scores have caused me to reflect. Are we looking too closely at short-term goals, such as improving these scores? Might our time and energy be better spent on intentionally creating high-performing cultures — cultures in which all patient satisfaction measures improve simply as a byproduct of seeking excellence?
During the past couple of months, I have noticed an increase in the number of senior executives, managers and directors of patient experience who want solutions to what are considered to be unacceptable patient experience scores. Their urgency is the result of the general public's response to recently released value-based purchasing scores. Leaders are becoming keenly aware that poor patient experiences are having a negative effect on VBP scores.
Poor VBP scores directly affect an organization's Medicare reimbursement, as well as its reputation for providing high-quality care in a compassionate environment. Could this urgency for a solution have been avoided by incorporating the use of strategic foresight — also referred to as "back casting" — in organizational strategic planning activities?
There's No Quick Fix
Since 2002, health care leaders and their boards of directors and trustees have focused on improving patient experience scores in anticipation of its impact on Medicare reimbursement. The three-year-old Affordable Care Act is a further catalyst for the much-needed industry upheaval; failure to achieve certain HCAHPS scores, and uncertainty of the provisions yet to be defined and enacted by the ACA, have caused more angst within the industry. For most organizations, there is no quick, tactic-based approach that will produce sustained improvement. Those with poor patient experience scores likely will suffer a reimbursement reduction for a number of years.
Many of my recent conversations have focused on tactics that can be quickly implemented and that increase the HCAHPS scores in nurse communication and responsiveness of staff. These specialties have been found to most strongly affect patients' opinions of a hospital's overall rating.
But what health care organizations' seeking a quick fix fail to consider is that creating a positive patient experience is almost always the result of an organizational cultural transformation, usually taking between three and seven years of intense focus and effort. The organizations that are successful in achieving top-decile patient experience scores engaged in strategic foresight as part of their future planning activities 10 or more years ago. These organizations were able to identify trends, develop plausible scenarios and implement strategies focused on addressing alternative futures.
Preparing for Multiple Futures
Richard Slaughter, creator of the Australian Foresight Institute, defines strategic foresight as "the ability to create and sustain a variety of high-quality forward views and apply the emerging insights in organizationally useful ways." Such strategic forecasting is used by organizations seeking to develop scenarios, based on what is known today, and to envision alternative futures that are 10 to 15 years away. Notice the plural in the phrase "alternative futures" — more than one is contemplated, as there is no way to predict one defined future accurately.
Strategic foresight is rarely used in health care, but health care organizations that are willing to incorporate strategic foresight into planning activities will have an advantage over those using the traditional strategic planning process. Traditional planning addresses short-term goals and processes meant to raise scores without actually changing organizational culture.
Although many of the ACA provisions are yet to be fully defined, we do know the three overarching objectives of the legislation: (1) to improve health outcomes and the patient experience, (2) to reduce health care-related expenditures and (3) to expand access to care across the continuum. Even with the knowledge of those three overarching objectives, strategic forecasting can identify plausible scenarios 10 to 15 years into the future.
A Case Example from Energy
Royal Dutch Shell, commonly known as Shell, is a multinational oil and gas company that has used strategic foresight since the 1970s. Thomas Chermack, in his book Scenario Planning for Organizations, details Shell's use of a scenario-based strategy. Leaders in the organization were able to notice evolving dynamics in the environment, before competitors, as they had visited and studied these dynamics during their scenario-building process.
The capability to correct strategies early provided Shell with a significant competitive advantage when oil prices were volatile in the 1970s. The assumptions on which leaders had based their decisions were influenced by the scenario development process; the leaders, therefore, held a wider view of their world. Integrating powerful tools such as scenario development into strategic forecasting allowed Shell to address impending dangers and make self-corrections to maintain global leadership in the volatile gas and oil industry. Shell remains one of the world's most valuable companies, topping the 2013 Fortune Global 500 list.
The few health care organizations that used strategic forecasting years ago have successfully positioned themselves to endure reimbursement reductions from federal and private insurers. Wise leaders, not knowing the exact future, carefully planned for the what-ifs by implementing operational efficiencies, strategically focused cost-reduction initiatives and mutually beneficial partnerships. The many organizations that did not initiate such future planning now are forced to cut costs indiscriminately, leaving patients and employees vulnerable to negative impacts on health outcomes, patient experience and organizational culture.
Envisioning Health Care's Future
The objectives of the ACA are well-known. It's not likely to be repealed, and if it is repealed, there is no alternative plan. The continued implementation and expansion of value-based purchasing is also here to stay. Although many of the future details and timelines for implementation of the ACA and of VBP are unknown, a short-term plan, myopically focused on raising specific performance measures, is no way to survive in this rapidly changing environment. An alternative is strategic forecasting, which will challenge the thinking in most organizations.
Consider taking time to examine thoughtfully how the future of health care will be impacted by the following eight trends: society, technology, energy, environment, economy, employment, population and politics. Individuals practicing strategic foresight refer to this examination as a STEEEPP analysis.
Once the analysis is completed, attempt to live in the future scenarios, then project backward to ways you can prevent some undesirable future scenarios from evolving. Or develop strategies that will actualize other scenarios, allowing your organization to adapt or emerge as a leader in the future. Frequent testing and revising the alternative future maps will significantly enhance the probability of your organization's success.
No one can predict the future, but using strategic foresight will reduce the chances of needing to contact a consultant in a panic, urgently attempting to identify a quick fix for something that could have been envisioned and possibly avoided years in advance.
Craig Luzinski, M.S.N., R.N., NEA-BC, FACHE, is the COO at Creative Health Care Management in Minneapolis.