" … There are known knowns; there are things that we know that we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don't know we don't know."

Of course this is the famous (or infamous) quote by former Secretary of Defense Donald Rumsfeld. It garnered support and detraction. The Plain English Campaign gave him the Foot in Mouth Award, but others heralded it as a "brilliant distillation of quite a complex matter."

For me, it always conjures up a searing pain in my head. It sounds like the hypothesis of some enormous evil SWOT analysis that will never be solved.

Many also might feel as though it summarizes the daunting task of planning in our new health care world, where uncertainty is a given. There are plenty of unknown unknowns, but just to make ourselves feel better, let's start with some known knowns.

The big one is: the certainty of risk. All health care is local and some pockets out there may remain untouched by system transformation, but their numbers will dwindle. Risk contracting based on quality and cost is coming, be it shared savings and loss, bundled payments or some form of capitation. And it doesn't matter whether it is a federal program or a commercial one. Leaders who recognize this are developing management structures, clinical integration strategies and risk management capabilities to get ready.

Business-as-usual is no more. Hospitals and systems around the country have been remarkably adept in a relatively short amount of time at putting together alliances, networks, affiliations, mergers — whatever you want to call them — that fit their individual situations and communities and markets. Sure, there is a high dose of stress associated with all this activity and many opportunities for mistakes and outright failures, but there also is real zest for experimenting, analyzing and calibrating new formulas that work — not just getting better at the same old business-as-usual strategies. In fact, that is the one tack that is not going to work.

Designations are not what's important. It doesn't matter if you are a designated ACO or not an ACO. It's the underlying capabilities that count. As one CEO in our cover story stresses, the capability is more important than the designation. "ACO is alphabet; it's what you do inside that counts." Developing those enabling capabilities gives the organization the agility to shift-shape as necessary or desired.

Value is the common thread. One thing they all share is a commitment to reorient health care from delivering procedures to delivering value. Value is defined as delivering evidence-based care, including coordinating care across the continuum, as well as clinical, financial and patient satisfaction outcomes for both individuals and populations.

Many very smart and experienced people say this is just not going to work — the results will not meet the necessary expectations. But we also know that the traditional delivery system is broken, doesn't meet anyone's expectations and cannot continue on the same trajectory. Many feel that for the first time in a long time, there is a strong sense that we are pulling in the right direction, with patients at the center of the system.

So bring on those scary unknown unknowns.

— You can reach me at mgrayson@healthforum.com.