A thorough understanding of some of the conceptual aspects of strategic planning (SP) is essential before it can be effectively implemented. Unless such understanding is achieved–which is not always the case–the process may be approached in a superficial manner, which is a common cause for the failure of SP.

There are many academic definitions, as well as others which, although not academic, have been applied successfully by those employing them.1 This demonstrates that what matters is the importance of the concept and idea behind the definition, rather than the definition itself.

Strategic planning is the systematic and organized process whereby an organization creates a document indicating the way it plans to progress from its current situation to the desired future situation. It is the set of decision-making criteria and the decisions taken and implemented by an organization to definitively and permanently guide its activities and structure.

We would like to highlight 2 important aspects:

• • First, it is assumed that the unit of production is not the individual but the organization. There is still a long way to go before it is fully recognized that a health professional working alone, even with sufficient material resources available, cannot solve all the challenges that arise in the current healthcare setting.

• • Second, SP has a clear transformational purpose: a) it identifies the current characteristics specific to the organization and the setting in which it operates; b) it generates a vision of how the organization wishes to be in the future; and c) it also defines the roadmap and actions required to change the organization's current situation to the desired future situation.

The following could serve as an academic definition of SP: “A proactive, structured process implemented by organizations consisting of the dynamic use of specific selected external opportunities that engage and develop internal competencies with the aim of fulfilling the organization's mission and creating value for its stakeholders”.2

An alternative definition could be “A set of processes carried out to identify the future desired by the organization and to develop guidelines for making the decisions leading to such a future. When an organization behaves reliably and consistently over time, it can be said to have a strategy. The strategy is a means that the organization chooses in order to move from its current situation to a desired situation in the future”.3

The term “strategic” has 2 components that should be highlighted. The first refers to the decisive importance4 that should be placed on anything considered to have a strategic role. This role is frequently conferred on trivial matters, which should be avoided to prevent misuse of the term. Secondly, the term “strategic” should only be associated with the medium- and long-term future (3 years or more) in contrast to the term “operational”, which applies to a time horizon of 1 year or less. “Strategic” denotes a highly substantial issue that cannot be associated with the short term.

There are 5 indicators that, in combination, would suggest the need for SP.5

• • Increasingly informed, demanding and nonloyal clients (with the capacity to choose). If we assume that patients are the only clients of a health organization (HO), it seems obvious that in the future the HO will be treating patients who are increasingly better informed, aware of their rights, demanding, and with a growing capacity to choose their healthcare provider, a decision that has consequences for financing the HO.

• • Increasingly professional and skilled competitors. The system of resident physicians, access to updated knowledge, and continuous training have led to the following: a) it is increasingly easy to find highly qualified trained professionals outside the major centers of large cities; and b) the high level of specialization and excellence among these professionals is increasingly widespread.

• • Limited resources for production. This factor needs little explanation, and even less in times of severe economic crisis. A possible response to this situation is the increased obligation to allocate resources on a rational basis, allowing only the best and most efficient HOs to remain.

• • Focus is shifted from the product or service to the client. The focus is no longer solely on the quality of the product or service, but also on how this is transferred to the client and their experience. HOs no longer simply focus on carrying out the processes to the best of their ability, but on achieving patient satisfaction and obtaining the best results possible. What matters is not only what, but how.

• • Size and complexity of the HO. Increases in the size of the population, their needs, and the diagnostic and treatment options offered has led to physical growth in the size of HOs and increased organizational complexity. A clinical service may already be too large a productive unit, and decomposing it into highly complex subunits may have to be considered. Another source of complexity arises from the need to act in collaboration with primary care in relation to a range of diseases, especially chronic ones.

All these circumstances clearly affect HOs, immersing them in an environment of constant and sudden change both in their external and internal circumstances, and those of their clients. In these circumstances, SP is a fully applicable tool that is both useful and relevant to the HO. If SP is not conducted, then in a few years HOs could become irrelevant or even cease to exist.

SP is a rational process that aims to bring the future closer and allows us to both study and conduct simulations of the future. The process can reveal previously hidden opportunities or threats,6 providing the option to act on them early. Strategic planning establishes a clear and explicit framework with criteria for making day-to-day decisions and identifying fragmentary and unaligned choices or personal value judgments, all of which facilitates and simplifies managerial decision-making. The development of SP encourages the participation and commitment of the entire HO in achieving the planned results, thus becoming an important element in institutional cohesion. Finally, an organization that has good SP and applies it consistently offers a serious and credible external image (corporate reputation).

Strategic planning is definitely not a bed of roses. It is expensive, especially in the amount of time invested by members at different levels of the organization, and may seem very tedious or a waste of time. Strategic planning may uncover differences or conflicts that were more or less hidden and which the members had learned to live with, thus making the situation during the process seem worse than before. Given that SP not an exact science, a genuine fear is that even with good SP an organization may still fail. However, in changing or turbulent environments, the risk of failure is obviously greater when no plan exists.5

Two common errors are not involving the right people and not addressing the really relevant issues due to their being too burdensome or complex. Another error is the failure to link SP to organizing the resources (financial or otherwise) needed to carry it out. Any strategic plan should be able to answer the question of how much it costs. Perhaps the most common error is to put all the effort into the planning stage, but fail to put the plan into practice. A variation of this is when its implementation is interrupted by the arrival of a new management team or head who wants to restart the entire process.

At the highest director in the organization, the chief executive officer (CEO) has the duty to promote the SP process and provides the organization with a plan for the future.7 Such planning is the most important core function of any CEO and is their raison d’être. Making plans for the future is probably the one function of CEOs that cannot be delegated and may represent their biggest “gamble” as heads of organizations. The CEOs can and should rely on their teams to create the plan and can also receive assistance from third parties (consultants). However, neither the team nor consultants can replace their initiative when analyzing the current situation, creating a shared vision of the desired future and identifying the best way to close the gap between reality and desire. Strategic plans cannot be purchased. However, methodological support can be purchased to develop the strategic plan. The executive board that does not plan (or buys a plan) is failing in its most fundamental task.

This issue does not have a single universally acceptable answer. In non-healthcare organizations, corporate SP is characterized by being generated at the strategic apex of the organization and sets out the main strategic areas (SA) that affect the entire organization without exception. Deriving from this, there may be a strategic plan for each business area in which the corporation is active. In addition, each internal department may have a functional strategic plan tailored to its needs. For example, a pharmaceutical company may have a global corporate strategy. Depending on this strategy, the department of heart medicines may have another strategy that differs from that of the department of drugs acting on the brain, which in turn could be different from the diabetes department, even though the strategic plans for these 3 departments will be completely consistent with the corporate strategic plan. Within the department of drugs acting on the heart, there may be a need to develop a strategic plan for Spain that could differ from that for Pakistan. Thus, within a sufficiently large organization, distinct strategic plans may coexist at different levels. The only requirement is that each of the strategic plans is consistent and aligned with any other or others at higher levels.

The same criterion should be applied in the HO. Thus, the Ministry of Health or Health Department should have a strategic plan and, within the Health Department, the regional health service should also have a strategic plan that is aligned with the former body. In turn, there could logically be a strategic plan for specialized care and, within this, a specific hospital could have a strategic plan. The only qualification for the implementation of strategic plans is that they should be well aligned with one other and not be in conflict or divergent. The justification for their existence is that that they pertain to a structure which, even though subordinate, is sufficiently large, complex and different from the rest of the organization.8 From this point of view, an integrated management unit, a clinical institute or a clinical service, depending on its complexity, may well need its own strategic plan which will differ from the current higher-level strategic plan. The only methodological requirement is that it is aligned with the higher-level strategic plan and is not in conflict or divergent. In recent years, and within the hospital-based cardiology, SP has been conducted for subunits such as hemodynamics, electrophysiology, clinical cardiology, noninvasive diagnosis, etc. Strategic planning is relevant when the subunit is sufficiently large, complex and specific, is clearly different from the rest of the service, and the plan is consistent with the higher-level strategic plan.

There should be a steering group within the HO to lead the development and implementation of a strategic plan6; this group should represent all interests and include people with leadership skills. Ideally, this group should be led by its chief representative, who will act as the driving force and display strong commitment to the project and should include someone who is familiar with SP methodology. The group must have real executive power to avoid being perceived as a mere planning entity.

When the HO is sufficiently large, it is very useful to provide a specific physical space (the SP Office), which is the epicenter of the planning process. Sometimes an “external facilitator” for SP is contracted; this is the person in charge of organizing, motivating, and networking all actions, giving them shape and connecting them in time and space. When required by the circumstances, this is a role often assigned to a consultant.

To address the different aspects of analysis and generate ideas, working groups have to be created that report to the steering group. These should be cross sectional and well coordinated to avoid duplicating work and to fully focus on the assigned tasks. The number of these groups will increase, the greater the size of the HO for which they are attempting to plan.

One aspect that may adversely affect the planning process is associated with the relative lack of strategic thinking among the health workers in the HO service.9 Healthcare professionals manage short-term situations very effectively and make quick decisions based on current diagnosis and treatment models and algorithms, which serve as a guide in taking clinical decisions. The long-term features very little in their daily work, which requires practical and immediate answers to specific problems that are usually tangible and quantifiable. Their work is usually efficient within the known, due to its repetitive nature. In contrast, physicians manage uncertainty and vagueness with difficulty and do not go looking for problems as these tend to arrive on their doorsteps and are usually routine. Physicians have a working philosophy of “hands-on” and “first line of action.” Strategic planning may present them with a challenge because they have to face problems that are not well defined, have no known precedents, evolve unpredictably, are barely quantifiable, and yet require a response. Physicians have problems dealing with ambiguity and problems that cannot be systematized.

To minimize any undesirable effects, the difference between the professional skills specific to physicians in the HO services and those required when they are placed in the position of participating in or leading a strategic plan should be taken into account.

The SP process is divided into successive phases, although it is recognized that progress may involve the need to return to some earlier stage in order to fine-tune it. The literature provides different names for distinct phases. This article takes a classical approach, which continues to be valid, identifying 5 stages in the process.

This is a written statement that defines the final aim of the HO, that is, its reason for being.10 Classically, this statement defines the overall purpose of the organization, the target clients, the services offered, its distinguishing features, the geographical area in which the HO operates, and sometimes the way it operates (quality, ethics, efficiency, etc.).

The mission statement should be short, clear and concise and its content should be shared throughout the entire HO. It should avoid any ambiguities and clichés that may hinder differentiating and identifying the organization.

The mission statement should be disseminated throughout the HO such that all the workers effectively know it by heart. In this sense, after its successful development and dissemination, it can become a rallying point for cohesion within the HO. In addition, clients can be informed of the mission statement as a formal declaration of commitment to a task and its recipients.

The vision statement is a written statement that presents the future image of the HO after the transformation process. The content of the vision statement should reveal what the HO specifically aspires to be in the future. It should also serve as an inspiration and pose an attractive and motivating challenge to be shared by the members of the HO. They should feel that this vision is achievable and that it is exciting to work with something that, currently just a vision, will be transformed into a reality.

Like the mission statement, the vision statement should be as short and well defined as possible so that the members of the HO can clearly visualize what the organization aspires to be in the future.

A well-formulated and widely shared vision statement exerts a powerful pull on all of the HO's members, who will thus be able to clearly see where the projects are heading.

Values are the set of principles, rules and cultural aspects governing the HO and determining their institutional behavior. They constitute the organization's ethical code that gives it its “soul” and “character”. These values predict a specific response by the HO when a situation arises that must be immediately resolved.

The values must be shared and widely disseminated.

The real values of an organization are those that actually govern its behavior and decision-making processes, whether they are formally stated or not.

The second phase of SP has 5 stages.

This analysis provides information on everything external to the organization that can influence it, but which the organization cannot change. The analysis of the environment focuses on 4 components:

• • Clients: it is essential that the HO identify its clients and what they can expect. They should be segregated using the criteria appropriate to each case (demographic, socioeconomic, etc.). It may be of interest to include in the client category other bodies relevant to the HO setting, such as the center's management or the clinical services that refer patients or receive them.

• • Competitors: they must be clearly identified and analyzed to identify the features that distinguish them from the HO and what makes them better or worse than the HO. Competitors are a major source of learning for the HO.

• • Providers: the HO should characterize and differentiate their suppliers, which are the source of necessary resources (goods and services) and which can have a significant influence on the quality and cost of the services provided. Recently, some providers have attempted to occupy a significant position in the production network in genuine collaboration with their clients to establish long-term partnerships that benefit both parties.

• • Owners: this term refers to the person, company or government body (public or private) that has ownership equity of the HO. The HO must clearly identify and understand their objectives and timing, and also understand the circumstances surrounding the activity to deal with expectations.

These four dimensions are those that form what is classically called the “business sector” and provide a good picture of the environment in which it operates. In addition to this static description, Porter11 proposes a more dynamic complementary analysis, which considers 5 environmental aspects: a) rivalry between competitors in the sector; b) entry barriers to the sector, their importance and characteristics; c) the threat of alternative products or services; d) supplier bargaining power; and e) client bargaining power.

This analysis provides information on everything relevant that has occurred and occurs within the HO. It is accepted that the HO has the complete ability to act, transform and change its internal environment. This analysis focuses on 4 different aspects:

• • Resources: an analysis is made of the HO's available resources, including people, financial budgets, structural resources (plant, facilities and equipment) and their degree of obsolescence, and organizational resources. Organizational resources may not be analyzed in sufficient depth, which would be a waste of the organization's enormous potential for improvement.

• • The legal situation: an analysis is conducted of the current regulations affecting performance, particularly those limiting or guiding it. If the question arises of whether to include this aspect in the environmental analysis (certain regulations cannot be changed from within the organization), the answer is that there is no methodological obstacle to doing so, although the impression must be avoided that nothing can be done about them, which is often not true.

• • Other power groups within the HO: trade unions, professional associations, internal decision-making bodies, clinical commissions, informal power groups, etc, may play a role in the life of an HO and, if so, it is important to analyze their degree of influence and impact on operations.

• • Analysis of clinical care, training and research activity: without doubt, this is the part of the HO's internal analysis with the greatest scope. It is important that the analysis is conducted over a long enough period to detect trends that may motivate taking strategic decisions. This analysis has to be addressed from the perspective of the quantity, quality and cost of production; comparing the HO's data to standard data and data from competitors is of maximum utility. The analysis of activity should not simply produce an avalanche of data but must be synthesized to highlight what is relevant and bring out any need to take strategic decisions.

The validation of the current list of services, defined as the set of different services offered to the clients, is an aspect that is often glossed over in analysis of activity. The list is usually determined by demand and habit, rather than by periodic critical review. Setting out of the list of services is probably the biggest exercise in resource allocation carried out in a HO, and should not be left out of the critical analysis during the SP process.

Once the exterior and interior analyses have been completed and integrated, the strategic plan steering group will now have a wealth of ideas about possible strategic actions that could be addressed in the strategic plan. At this point, the issues identified in the analysis are classified into four categories to better understand what to do and in what order. This is the SWOT analysis, an acronym formed from strengths (S), weaknesses (W), opportunities (O) and threats (T), which classifies the results of the analysis.

The external analysis identifies both the opportunities offered by the environment that the HO should take advantage of and use to design its action plans, in addition to threats to the HO from which it should protect itself and minimize their potential impact. The internal analysis identifies weaknesses, which are issues that the HO should try to limit or correct, and strengths, which should be the subject of strategic actions to consolidate and develop them, and from which the maximum performance should be obtained. Depending on the importance that each organization gives to each of the results, in addition to classifying them using SWOT criteria, they can be weighted in terms of importance or relative intensity (high, medium and low; +, ++ or +++, etc.), which allows the planning team to establish a ranking, with the most important factors ranked in the first position, oriented to strategic priorities.

Throughout the process developed so far, the planning team has been able to generate numerous alternative strategic actions. All these proposals are now formally entered in a document, without judgment regarding their feasibility or relevance, and where no idea is rejected without due consideration.

Armed with this set of proposals, the strategic plan steering group begins a process which classifies and groups them into more or less defined areas of action. These areas of action are also simultaneously identified and named depending on the type of proposals they contain.

Based on the various discussions that have identified them, the strategic action selection process is fine-tuned; some proposals are discarded whereas some are linked to other proposals, thus better defining the fields of action each time. At this stage, the wide range of options for action that were originally suggested are narrowed down to some extent, leaving aside those that clearly do not meet the minimum conditions of feasibility or do not have the desired scope.

The strategic plan steering group concludes this stage with a set of no more than 20 areas of action, which constitute the strategic options from which the subset that will definitely form the final strategy formulation is chosen.

The strategic plan leader and steering group now choose the few areas on which to focus the strategic action of the HO during the coming years. These are what are classically called SA, which must bring together the following features:

• • Number: there should only be a few (<10) SA, preferably about 5 or 6, to ensure that the HO effectively invests its effort, concentrating on a few strategic areas and sacrificing the rest for future planning. The desire to do everything blurs the desired strategic direction and reduces the pressure that can be brought to bear on each point.

• • Duration: the SA must remain active for the duration of the strategic plan. Thus, the areas for action chosen have to be those that will be open to intervention over this entire period. An SA has no expiration date in a strategic plan, except under very exceptional circumstances, as discussed below.

• • Name: in line with the above 2 points, the name of the SA should be generic, such that it refers to one area of action alone and is not oriented toward a particular action. For example, it would be better to talk about “Quality” rather than “Plan for Improving Quality”, as the former term can include the latter, as well as other actions.

Once the SAs have been identified and denominated, the classically named strategic objectives (SO) are assigned to them, which are wide-ranging actions performed within a specific SA. The number of SO assigned to each SA should not exceed 5, and like them, should be conceived in such a way that they are valid for the entire lifetime of the strategic plan. The drafting of the SO should make relatively explicit the actual direction to be followed within the SA. Its formulation is much more specific and recognizable in practical terms, although it still retains its strategic character. Imagine that we are in the SA “Quality”; an SO could, for example, be “Accredit the HO and retain its accreditation”.

The SA and SO together in an organization constitute what is called its strategy formulation, which should only fill 1 or 2 pages and make explicit the strategy of the HO.

At this point, it is advisable to fine-tune the strategy formulation developed, based on the perspective proposed by Porter,12 to see if in fact a strategy exists by asking the following questions:

• • Does the formulation provide a strategic proposal that will lead the HO to a genuinely unique position compared to the previous position and to that of the competitors?

• • Does it offer value in a different way?

• • Have any decisions been taken that involve other actions being stopped? Will services be cut?

• • When certain activities stop, does that change the way operations are performed?

• • Are the strategic choices that have been made valid in the long term?

If there are negative replies, the formulation should be reviewed to check whether, instead of forming a strategic plan, a plan has been created with a far more limited scope.

The aim of operational planning is to make each SO absolutely specific, practical and recognizable. The way to do this is by assigning operational objectives (OO) to each SO. In the draft, the OOs must be completely clear and specific such that the reader can identify exactly what is intended. Statements such as “increase the number of X by 20%”, “reduce the number of appointment errors below 1%” or “reduce delays on the waiting list to a maximum of 60 days” should be used and expressions like “strengthen”, “improve” or “coordinate” should be avoided.

The OOs bring together the following characteristics:

• • They must have a fixed and recognizable duration, always less than 1 year. Intermediate goals can be established to be carried out in different stages over time.

• • They should be clearly quantified. To track their degree of completion, indicators that measure this are frequently needed.

• • They should be challenging and keep the HO in a state of alert in order to achieve them.

• • As a qualification to the foregoing, the OO should be achievable. It would be unreasonable to have OOs that are a priori unachievable, because the HO would slacken and decrease its efforts. An excessively demanding OO has a contradictory effect and demotivates the HO.

• • Each OO must have a designated person in charge, who really has the power to alter the performance of the unit or subunit.

• • Each OO must have a cost assigned to its implementation, such that the total cost of all the OOs is equal to the total cost of the strategic plan.

• • Each OO must have the funding and other resources (staff time, equipment, etc.) necessary to achieve the objectives.

Once all the OOs are formulated, the implementation of each has to be integrated with that of the others within a time-line of action that includes all of them and provides an overview of the links, timing and sequence of tasks, as well as the combined efforts that the HO has to perform at every stage.

Formulating a strategy is always a gamble whose outcome is uncertain. Although the technique and the planning method may have been ideal, it remains an imperfect process due to various factors: a) the strategic choice may not have been the best; b) some factors may not have been sufficiently evaluated; c) implementation errors may have been made; d) the expected impact of the actions chosen may not have the scope initially envisaged; and e) during the implementation of a strategic plan, the external environment or the HO may undergo changes that invalidate or modify the initial analysis.

Thus, the way in which the steering group plans to keep track of the degree to which the objectives have been reached is an inseparable part of the strategic plan. Tracking is done by obtaining internal information based on a dashboard system that includes the indicators defined in the OOs. External information should also be obtained to detect changes in the environment that may involve substantial changes to the information used to establish the strategic priorities.

When tracking, the steering group must ensure that an overload of information is not generated and that indicators are grouped into logical and consistent sets, which are as integrated as possible. In addition, the steering group must design an appropriate information distribution tree for each HO management center and ensure that each OO leader has the necessary information available.

Assessing the results of the strategic plan should be done on a collective basis by the strategic plan steering group and each working group, at least once every quarter.

Based on these assessments, changes to one or several of the original OOs may be proposed to the strategic plan steering group and these changes may be accepted or rejected.

The last part of the strategic plan concerns its capacity to have its more strategic aims modified. If there are warnings that OOs grouped around a particular strategic plan are having to be systematically changed, one possible explanation is that the SO itself has been poorly chosen.

The strategic plan should have the capacity to allow this change to occur, although the need for change should be compelling and the reason for change should be thoroughly documented. An SO should only be changed after deviations have been regularly observed over 1 year, or when significant changes, unforeseeable during the initial planning stage, have occurred in the environment or in the HO.

Several SOs may undergo systematic failures in the same SA, leading to the possibility that the SA itself is incorrect or that it has been undermined by internal or environmental changes. Then and only then should the strategic plan steering group change that particular SA. These changes should be made as a last resort.

Strategic planning is a useful tool for steering HOs, which may include a cardiology or a specialized unit (eg, electrophysiology) in certain circumstances. The unit leader is in charge of planning, which is a systematic, rational and integrative process that focuses the organization on the necessary, relevant and sustainable transformations for the future.

None declared.

Corresponding author: María de Portugal 11, 28005 Madrid, Spain. franciscodepaula.rodriguez@medtronic.com