Hywel Dda’s leaders audited all of the system's previous strategic priorities to remove any overlap or obsolescence, and reaffirm the system’s long-term trajectory. The chief executive, with support from the strategy director and the project management office, reviewed 458 strategic “priorities” that had built up, unchecked, since 2017. The priorities fell into three buckets:

1. Previous strategic recommendations: 2017-20 strategic plan, long-term system transformation plan
2. One-off recommendations and national guidance: top-down recommendations from the Welsh government, quality assurance targets
3. Current strategic priorities: the new 2020-23 strategic plan, Covid-19 response requirements

Within this sprawl, the same goals often appeared numerous times in different formats and within different plans, leaving ample room for simplification. Leaders first examined the previous priorities to identify where mandates overlapped. They also checked to see if any goals were no longer relevant and whether they were missing any priorities critical to the pandemic response and recovery. Next, the chief executive and the deputy chief executive (who also serves as the Medical Director) worked with the board to reorganize the priorities into a clearer strategic framework. They challenged each board member to draft their own priority framework based on the audit's results and Hywel Dda’s current challenges. The chief executive and deputy chief executive synthesized Hywel Dda’s new strategic framework out of feedback from the board members. Since the board had given their input throughout the process, they gave their approval shortly after the final version was complete.

As executives designed the strategic framework and consulted with the board, they developed a new way of thinking and talking about system priorities. This narrative reflected the mind-shift executives needed to embrace to ensure flexibility in the organization’s planning process. This narrative has two layers. On top are the broad, aspirational objectives that the organization is continually chasing—its “true north.” Below them are time-bound tactical moves they’ll make in the direction of true north. These tactical moves are time-bound, iterative, and measurable.

Hywel Dda’s chief executive used a sailing metaphor to describe this plan. The organization’s six strategic objectives (its “true north”) are “smudges on the horizon.” Those objectives are ideals rather than specific targets, since the organization should still be moving toward them in three years, five years, or even a decade. Five of the six strategic objectives came from previous cultural values or strategic priorities, meaning that staff and leaders were already familiar with them. The sixth was borne out of a need to conserve resources during and after Covid-19.

Hywel Dda’s six strategic objectives lay out its long-term identity:

1. Putting people at the heart of everything we do
2. Working together to be the best we can be
3. Striving to deliver and develop excellent services
4. The best health and well-being for our individuals, families, and our communities
5. Safe, sustainable, accessible, and kind care
6. Sustainable use of resources

After naming the six, high-level strategic objectives, Hywel Dda drafted 65 tactically oriented “planning objectives” to move the organization toward the strategic objectives over specific time spans. To carry the sailing metaphor further, if the strategic objectives are “smudges on the horizon,” then the 65 planning objectives are the “paddle strokes” that Hywel Dda will make to achieve them. Each planning objective falls under one of the six strategic objectives and has defined metrics and timelines. A single executive director oversees each planning objective by working with managers at the unit, division, and department levels.

This new way of thinking and talking about strategic priorities allowed Hywel Dda to shift from static to dynamic planning. Leaders constantly scan the horizon to see if they need to pivot left or right—update, add, or delete objectives—to keep “sailing” toward their true north.

Here are two examples of what this looks like. For the strategic objective “putting people at the heart of everything we do,” there are about a dozen planning objectives (“paddle strokes”) to move in that direction. For instance, one planning objective is to design a training and development program that would build excellent customer service for all staff in public and patient-facing roles, and to have the program running by April 2021.

Another strategic objective is “sustainable use of resources.” One of a paddle stroke under that objective is to develop a plan to make all services carbon neutral by 2030 and begin its implementation within the next three years.

These are just two examples of the 65 concrete goals that Hywel Dda detailed. Achieving each of these goals will bring the organization closer to their strategic objectives—those “smudges on the horizon.”

Being flexible while developing and executing strategy requires continuous monitoring of the operating environment. To ensure the freshest situational analyses, Hywel Dda created two steering groups that constantly scan the environment and bring any new mandates to the board and C-suite. These executives can then add, subtract, or change any of the 65 “paddle stroke” objectives to better steer the ship.

To do this effectively, Hywel Dda divided the analytical responsibilities across two teams. One team scans the broader health care environment to identify emerging pressures and develop novel solutions and approaches to address them. The other team assesses the feasibility and timelines of implementing these new solutions based on resource availability.

Collectively, these two teams provide an efficient funnel for new strategy proposals to flow to the c-suite. The Transformation Steering Group (TSG) operates as the top of the funnel to generate new observations, insights, and plans. And the Strategic Enabling Group (SEG) works as the filter to help the board select the solutions with the highest likelihood of success.

Responsibilities and composition of the TSG-SEG steering group dyad:

1. Transformation Steering Group: Scans the environment for new mandates or external pressures and crafts intelligence-based proposals for new planning objectives. Proposals clarify why the new objective is a priority, and what purpose it serves.

• Representation from: Chief executive; medical director; board members; and directors of finance and planning, performance, informatics, and commissioning

2. Strategic Enabling Group: Establishes resource requirements and a timeline by which Hywel Dda can achieve new objectives that the TSG proposes. If the timeline and resources necessary are viable, the proposal is sent to the board for a ratification process.

• Representation from: Procurement and sourcing; capital and estates; workforce, data, and informatics; legal; and finance

When Covid-19 erupted across the U.K., Hywel Dda implemented the NHS’s Command and Control Structure to ensure lockstep across the continuum of care. Hospitals and community organizations typically set up command-and-control structures during disasters to clarify decision-making authority, task ownership, and resource management.

After the first wave of Covid-19, Hywel Dda wanted to translate some of the key elements from the command-and-control structure to their internal decision-making and execution processes. In their new formation, executives approve (or decline) proposals for new planning objectives that the TSG-SEG dyad brings them. Once a planning objective has been approved, the responsibility for implementation is cascaded down to managers and their teams. The rationale is that those closest to the work should be the ones making the changes.

Hywel Dda uses a medal nomenclature to describe which parts of the organization have which responsibilities. The gold group (the board and chief executive) ensures the system progressively moves toward their six strategic objectives. They decide if a new planning objective proposal is in service of those six strategic objectives, and thus worth pursuing or not. Once ratified, the gold group passes the new planning objective onto the silver group (executive directors) to create plans to achieve each planning objective. The bronze group (unit/divisional directors) implement these plans and see them through to completion.