Today’s Strategy Planning (SP) process is not your father’s SP process!  SP use to be a 3-to-5-year planning window.  This is obsolete in today’s environment.  Now, SP is all about creating annual rolling operating plans that are updated yearly and are truly helpful tools to assist hospice organizations navigate a complex environment and strengthen performance in the areas of quality, growth, and finance.

Hospice Advisors works with non-profit hospice organizations to develop a simple but powerful approach to strategy, objective, tactic, and deployment.  With the emphasis on deployment and execution.

This article is a case study of a SP development and deployment process for a non-profit hospice company that was at cross-roads in its development as an end-of-life provider.  Shared will be the journey took through the SP process, methodologies used, a framework for the strategic plan and benefits from the process.

Why Bother with Strategic Planning?

For non-profit hospices, the world continues to change.  Since the “provider flip” started to occur in the earlier 1990s, non-profit hospices have been threatened.  When the hospice benefit was first enacted in the mid-1980s, 90% of the hospice providers were non-profit and only 10% were for-profit.  Today, 90% of the hospices in the USA are for-profit and only 10% non-profit. The last non-profit hospice that opened was 14-years ago and during this time, several non-profit hospices have actually closed! There is a slow extinction of non-profits occurring in the country.  2020 demonstrated the largest amount of hospice acquisition and consolidation in recent years.  This is a function of the tremendous amount of equity investment money in play and this phenomenon further threatens non-profit hospices.

The reason to complete a SP for non-profit hospices is so that the organization can maintain and embrace their non-profit mission and charitable work.  While at the same time start to function with a for-profit mentality to compete in a every changing and competitive marketplace. Yes, we said for-profit to non-profits and that is not a bad thing!  You have heard from lots of folks the ole’ saying no margin, no mission.

The biggest challenges facing non-profit hospices come from within by attempting to do many things that take away from strengthening and growing the base business of hospice. The goal should first and foremost be a great hospice, but many hospices can be very distracted by focusing on continuum of care and programs that fall far outside of hospice and end of life care. Because non-profits have so many internal competing programs and services, the ability to execute and complete any level of strategic work required is difficult.

While we appreciate and understand branding many non-profits decided to change their names and loose the word “hospice”.  Many of these programs had very rich history and had referral name recognition but decided that by losing hospice in their name may in fact increase their hospice business. On the flip side we hear from hospices that they we wish consumers would use “hospice” sooner and understand “hospice.” Not understanding consumer behaviors related to death and realization that our primary hospice customer is our referral sources is a big mistake that many have non-profits have made.  Check out the national data and you will see non-profit market share has steadily decreased since 2014.

Additionally, non-profit Boards while very well meaning, generous and compassionate community leaders, lack in depth and expertise in end-of-life care.  Primarily because the Board does not truly understand the business of hospice, the changing health care environment, and the complexities of competing in an ever-increasing competitive marketplace this causes a dilution of focus and accountability. Driven many times by services and programs that are charitable in nature but fringe in the ability to serve more hospice patients.  Engaging the Board in a SP process enhances their ability to better understand the challenges facing hospice organizations and support the important work required to go from good to great hospice care!

Hospice Advisors SP focuses intensely on strategy deployment as well as development. Our model of SP emphasis deployment and execution.

The Hoshin Model and Approach to Strategic Planning

The beauty of the Hoshin method of planning is how it draws upon the collective wisdom of the organization in both the development and deployment of strategy.  Most SP stall-out because they do not have a strong mechanism and process for execution and deployment of strategy. The Hoshin approach when followed assisted organizations with execution to achieve desired results.

Below is an illustration of the Hoshin process.

The process starts by validating the mission and vision for the organization.  In most cases, the vision holds true along with the mission. If adjustments and modifications are required, a process would occur with Hospice Leadership and the Board to accomplish this.

The SP process includes an internal and external environmental scan. This scan involves a review of data and information, a survey of the employees and interviews with key people.  This information is analyzed and prepared to be presented to the Hospice Leadership and Board.

A wonderful benefit of Hoshin Planning is the ability to inform and educate the Board (and Leadership) on the current hospice environment and challenges facing the organization.  We share the information obtained from the environmental scan in a Hospice Board and Leadership in a SP Advance. We do not hold planning Retreats, but rather Advancements. Looking to the future.  An important us of words!  Board education and development assists the Board on how best to guide, focus and support the organization. A big plus is using a passionate hospice centric group (like ours) with many years of experience to deliver this challenging news to your board.

By engaging the Board and Leadership in an education and work session, a compelling internal business statement and set of key Break-through objectives are identified and become the architecture for the SP.

Compelling Business Statement

The compelling business statement supports the mission and vision of the organization and becomes a filter by which the Hospice can measure the rightness of its actions and the resources applied to advance the SP.  Following is an example of a compelling business statement.

As a non-profit provider of end-of-life services, we are committed to our mission and community work. We recognize however that the rapidly changing environment requires we have a laser focused plan on how we advance our core business of hospice.  This means that every strategy developed should originate from a basis of value to our healthcare community, our overall business and financial performance.

From the compelling business statement flow a set of break-through objectives.

Break-Through Objectives

Usually, three to five high level break-through objectives are identified that support the compelling business statement. These objectives then provide an opportunity to tap into the collective wisdom of the organization to start to develop tactics and actions that will advance the objectives over a 36-month period.  The first 12-months of the SP become the operating plan for the hospice. Following are an example of some break-through objectives:

1. Grow the hospice census by increasing the number of hospice patients admitted, improving length-of-stay and converting patients and families from other parts of our continuum of care to hospice.
2. Expand our continuum of care offerings to ensure we provide value to the greater healthcare continuum in our community while assisting us to grow our core business.
3. Develop and intensify financial controls, hold people accountable to performance targets and expand alternative revenue sources.
4. Invest in our employees by innovating how we can stay competitive with all the healthcare institutions in our community.

Tactical Development

The development of tactics and actions are the “guts” of the SP. And one of the more fun parts of the process.  Work groups are formed around each break-through objective. Using a variety of brainstorming exercises, a set of tactics and actions are identified. Using “Catchball” (a technique for creating and maintaining open feedback loops across all levels of your organizational hierarchy) the tactics and actions are refined.  Following are a few examples of tactics and actions.

Refocus and Strengthen the Sales Model and Approach

Assess current sales resources (Account Executives and Clinical Liaisons)

Re-assign and/or hire sales staff to achieve tighter, more manageable territories with a deeper penetration into referral segments, which yield longer length-of-stay

Continue to install a professional sales model (move away from “Muffin Marketing)

• Skill set development of 7-step sales process. Strengthen “Cold Call” approach. Learn to “Weed the Garden”
• Selling on value to 10 key segments
• Use of value-added collateral materials, i, e, Case Study, relevant articles, trigger sheets, etc.
• Phraseology development

Each AE to develop, work, and update a Quarterly Growth Plan 

• Focus on referral segments that will yield longer length-of-stay

Start to focus on referral segments that yield longer-length-of-stay

• Start a process to work Personal Care/Private Duty companies; follow protocol for working this segment; include in quarterly growth plans
• Start a process to work Assisted Living Communities. Initial focus to be on CCRC (Continuing Care Retirement Communities); Apply “Facility Care Planning” process; Include in quarterly growth plans
• Start working the Disease Management Associations; Implement sales process tailored to this segment; Include in quarterly growth plans

Redesign the Palliative Care Program to be tighter in scoop and with a key performance measure of conversion to hospice

New PC Program Vision and Definition

• PC Model description
• Target Populations
• Geography/Referral Source
• New Screening Criteria and Tools

Intake/Conversion Process from PC to Hospice

• Start with Identified patients that have long lengthens of stay. Hold a dialogue.
• Target clinical indicators to begin to introduce hospice.  Triage patients
• Determine how to identify and remove hospice barriers for PC patients and their families
• Transition plan for patients with prognosis of +1 1⁄2 year off PC.

Marketing

• Evaluate the ability with SNF for PC and Hospice
• Create a well-defined sales and marketing plan based upon goals of the new PC program
• Strategic use of RN Liaisons

Deployment and Execution

This is where most organizations fall-down. The Hoshine approach to SP places a strong emphasis on deployment and execution. There are several key elements that are focused on during this step in the SP process.

1. Accountability is assigned to the deployment and execution of each objective and high-level tactics. A staff member is given responsibility and accountable for advancing the objective/high-level tactics to assure work is occurring and movement is taking place. Assigned staff are accountable to Leadership for what is occurring and needed support.
2. Key Performance Indicators (KPI) are assigned to each break-through objective. Leadership and Management reviews the KPI monthly and uses this information to modify and adjust actions and approaches to better advance the objectives. These KPIs are shared with the Board as a method to update them on progress.
3. Project Management. The most valuable tool for deployment and execution is a project management tool!! The project management tool holds all the objectives, tactic/actions, who is accountable and timeframes. The entire plan can be viewed and provides an ability to determine what adjustments need to be made.  Leadership and management use this tool to monitor the plan monthly progress. Using a project management tool is key to success.
4. Work Groups. Work groups are formed around each objective and those large “meaty” tactics. These groups make sure “the-work-of-the-work” gets done, use the Project Management tool to guide and update the work and report directly to Senior Management for support and as a point of accountability.
5. Annual Review and Update. On an annual basis, the SP is reviewed and the existing and/or new tactics roll-forward into the new planning cycle.  In essence the SP rolls forward and build on what has occurred year-to-year.

Conclusion

Hoshin SP can assist non-profit hospice organizations further advance their mission and charitable work while developing the business acumen to serve more people, improve operations and finance, grow and give the gift of hospice.  Through the development of a compelling business statement that is supported by break-through objectives and tactics a clear path to organizational improvement will occur.  Coupled with a superior deployment and execution plan and set of tools, the rigor and cadence required is achieved to be successful.

Kurt A. Kazanowski MS RN CHE

Greg Grabowski

Hospice Advisors

296 S. Main Street, #202

Plymouth, MI 48170

www.hospiceadvisors.com

1.734.658.6162

The book provides a wealth of resources that I learned and gathered from being the owner of Homewatch CareGivers, a personal care home health company in Plymouth, Michigan. The stories and lessons from the thousands of families my agency has cared for has also contributed to hundreds of resources and helpful tools on aging and end of life issues. Use this as a tool and gain something of value in your experiences and interactions with your aging parents.

The 7 Chapters cover a range of topics, from how to talk with your parents about age related matters, “the talk about driving,” accepting a caregiver in the home, and knowing the signs of caregiver abuse to assure the safety of your loved one. It also discusses those special cases prevalent among seniors, like Dementia and Alzheimer’s disease. I also address the gift of hospice and all its myths. Finally, the book ends with how my relationship with a beautiful Russian woman led to the opening of my home care company in Moscow.

Why read this? I wrote this for the adult children in need of guidance when making tough decisions for their loved ones. Forget the boring textbooks… My lessons can be applied to any personal situation. I hope you are as excited about the book as I am. Stay tuned for more!

~ Kurt Kazanowski, MS, RN, CHE

The Wall Street Journal article basically said that For-Profit Hospices offer sub-par care. Both the article and NPR panel, in my humble opinion, were both misleading and didn’t address the true issue which was “what do consumers need to know in selecting the best hospice for them?”

I have worked for both types of hospice companies and to be completely honest, there are good and bad in both. The big claim in the Washington Post article is that For-Profit hospices skimp on nursing visits. I have never found that the case. And there are some Not-For-Profit hospice who act more like fund-development companies than hospice providers. So, again, this calls out in a LOUD voice, “what criteria should people looking when selecting a hospice company that is best for them?”

Here are a few questions that every customer should ask a hospice company they are interviewing.

1. What is your turn-over rate in your organization? The national average is 15% for hospice companies. If the company you are interviewing has a higher turnover rate you need to understand why!
2. The average caseload for a nurse. The national average is 13 patients per nurse. Obviously this number is going to fluctuate based on the hospices’ census. This is a KEY question to ask and understand.
3. Are your physicians Board Certified in Hospice and Palliative Care Medicine. Just like you won’t go to a Family Practice Physician for Open Heart Surgery (you want a Board Certified Cardiovascular Surgeon), you want a physician who is Board Certified in Hospice and Palliative Care Medicine on the hospice company team you select.
4. Does the hospice have Full Time physicians? You want to know if the hospice you select has a full time Medical Director.
5. Does the hospice offer all 4 levels of hospice care? There are four levels of hospice care: Routine, Respite, Continuous Care and General Inpatient (GIP). Does the hospice you select offer all 4 levels of care? Ask for details in how they offer these 4 levels of care.
6. Does the hospice offer General Inpatient Hospice (GIP) care? The GIP level of care is the “ICU” of hospice care and is intended to care for patients who have break-through pain and symptom management issues. You need to know and understand how the hospice you select delivers this level of care should your loved one ever need this specialty type of hospice care.
7. Does the hospice offer Music Therapy? The basic hospice benefit does not require a hospice to offer Music Therapy. If the hospice you select offers Music Therapy they are far be on what the basic hospice benefit requires!!
8. How many volunteers does the hospice have? The use of volunteers is part of the Conditions of Participation a licensed hospice must offer. Ask how many volunteers the hospice has and how many volunteer hours the hospice provides per month.

These are a few questions that will help guide you in selecting the best hospice for your loved one and you. So it is NOT an issue of For-Profit vs. Not-For-Profit but rather which hospice company offers the most outstanding care. You, as a consumer, need to know what makes a hospice excellent, good, bad or just so-so. The answer to these questions will help guide you in your interview process as you select a hospice.