Prioritization and Deselection: “Moving at the Speed of Trust”

Posted on by Jeff Hunter

“Moving at the speed of trust” was the phrase a senior physician leader used during my recent Patient-Centered Strategy workshop. His observation was that senior leadership teams struggle because prioritization and deselection require real choice-making among alternatives. It requires a team to say “not now” to a good idea because the capacity does not exist to act on that good idea at the present time; and that can anger an important constituent. Such decisions require the team to put the options on the table and make decisions; but more importantly, to stick to the decisions made. And that requires trust.

Prioritization and deselection are not difficult in a one-time event. After applying criteria to the defined initiatives, people walk away with a list of their top priorities. But a common problem in healthcare organizations is that prioritization decisions don’t seem to stick very long. Deselected projects worm their way back into the work-in-process by returning in a different form, a revised scope, or with new sponsorship. This diminishes focus and breaks down alignment of human and financial resources on the most important breakthrough initiatives. It leads to organizational overburden and gridlock, and the result is susceptibility to fast-moving competitors or new entrants.

There are many reasons that contribute to this challenge for leadership teams. In a “professional organization” like a hospital or university, autonomy is a sacred value and autonomous professionals can exhibit de-facto veto power through their behavior. With so many forces intruding on the patient-provider relationship and threatening the ability of the provider to control their world, they want to influence decisions that impact that world. When you put hospitals and universities together in an academic medical center it can make prioritization doubly tough.

Historic mental models also treat strategic planning as an event that happens periodically. Even when an organization refreshes its strategic plan annually, faster-moving environmental and industry forces challenge the annual batch-and-que systems typically employed in strategic planning events. Since emerging ideas move faster than the batching system designed to prioritize them, people find alternative ways to get their idea resourced. This often involves finding sponsors up the organizational ladder that can negotiate, barter, or coerce the idea into work-in-process. I was a poster child for this behavior; I built my career on knowing who to approach and how to approach them. These neuro-like networks exist in most organizations. While they may result in action, they do not lead to a nimble, focused organization or trust in leadership as a team.

Since the root causes of overburden are more behavioral rather than mathematical, adding more math won’t solve them. Countermeasures to this problem of prioritization/deselection start with viewing strategic management as a system by which the organization manages vision and strategy with agility. Strategic management is a process, not an event. Strategic management is the process by which leadership at all levels choose which issues and opportunities to solve for now and defer others until there is capacity to solve for them.

Another senior leader recently lamented on the sheer number of possible projects generated in the organization resulting from reading literature, attending conferences, and being approached by vendors. Patient-centered strategy uses the lens of the customer to decide which opportunities have the greatest potential to improve the lives of patients from the patient’s perspective and create a unique bond between the organization and its customers. Organizations can benefit more from insights that come from patients and the frontline caregivers who intersect with them; let them balance the perspective we receive from vendors.

In many organizations, the burden of proof is placed on those who think an initiative should be deselected to defend their logic, rather than requiring the initiator of the project to defend why it is critical now. Patient-centered strategy compels leadership to use visual management and leader standard work in a continuous process of seeing the strategic options, deciding which to pursue now and which to defer, and initiate dialogue throughout the organization, vertically and horizontally, to align the priorities and dedicate the resources.

Some of the best breakthrough work I am seeing occurs where teams resist the urge to overbuild a solution. Instead they treat their idea as a hypothesis and deploy small tests of change. Patient-centered strategy uses rapid experimentation with lean learning loops to deploy priorities in the most efficient and effective way. It uses Plan-Do-Study-Adjust (PDSA) thinking to determine if the initiative is truly creating unique value for patients. The use of visual management and leader standard work compels the team to continually answer the question “are we dedicating the right resources to the right initiatives to accomplish our customer-focused breakthrough objectives and move our driver metrics?”.

The visual management and leader standard work in this strategic management system is consistent with that used in your overall organizational excellence system. Using it enables leadership to reduce firefighting by becoming more intentional and proactive in the deployment of strategic intent. However, making choices visible can introduce what another senior leader called “the anxiety of transparency”. She said that initially the transparency of choice-making also increased accountability, and at first that made her uncomfortable. But over time, she felt liberated by putting options on the table, making decisions with her peers, discussing those decisions with those impacted by the initiatives, and managing those decisions using PDSA thinking where the team would learn together through experimentation, rather than argue about who is smarter or who is right.

And that builds trust. The organization moves faster with the speed of trust.


Jeff Hunter, Faculty


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