Advisory Board's international team hosted three global executive summits—one for Europe and the Americas, one for the Middle East, and one for Australasia—across November and December 2020. More than 40 health system CEOs joined and shared how the pandemic has changed their priority lists and how they are adjusting strategy accordingly. Below are the five biggest takeaways from the discussions.

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1. The annual, 'event-based' strategic planning process is too slow for today's operating environment

Strategic planning hasn't changed much in recent history, but Covid-19 is pushing executives to question the utility of old ways of working. As one CEO described it to the group, "I think in health care, the notion of annual strategic planning—where we rent out a 3-star hotel, everyone shows up in slippers, and we begrudgingly get it done—is now completely out of date. The name of the game now is being dynamic, being able to instantly pivot if we need to…not having a pre-set plan and sticking to it for 12 months."

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We heard from one health system—Hywel Dda University Health Board in Wales—that created a new strategic framework that embraces agility and nimbleness in the wake of the pandemic. Hywel Dda's leaders took the time to audit all organizational priorities after wave one, to declutter and reaffirm their aspirational identity. They reorganized their sprawling list of priorities into six strategic objectives that serve as "smudges on the horizon"—ideals that should still be the system's "true north" in a year or in a decade. The smudges aren't simply boxes to be checked off—examples include "putting people at the heart of everything we do" and "striving to deliver and develop excellent services."

A level below these six strategic objectives is where the flexibility comes in. Hywel Dda created 65 planning objectives that pursue the six ideals. If the strategic objectives are smudges on the horizon, then the 65 planning objectives are the "paddle strokes" that Hywel Dda will make to get them there. These are your improvement projects, new care standards, new builds, virtual visit and workforce targets, and so forth. To remain agile and flexible, the organisation then created two steering groups responsible for constantly scanning the environment and bringing any new mandates to the board and C-suite. With that new information, the board and C-suite decide whether to add, subtract, or tweak any of the 65 "paddle stroke" objectives. And lastly, they codified a process to allocate responsibility for any new objectives across the system, down to the frontlines.

Overall, this language of "smudges on the horizon" and "paddle strokes to get there" in the strategic planning process resonated in our CEO summits more than any other emerging idea.

2. Staff burnout, retention, recruitment, and resilience are up-at-night problems across all provider types and in all jurisdictions

We heard loud and clear that workforce issues are the biggest up-at-night executive priority heading into 2021, and for good reason. Covid-19 has pushed the health care workforce to emotional exhaustion and now threatens to erode in months the strong levels of engagement health systems have spent years building.

But leaders in our CEO sessions also talked about the new workforce opportunities that emerged from Covid-19. Flexible staffing is more reachable than ever. There has been a surge in nursing and medical student applications, pointing to an eventual rebalancing of clinician supply. The stigma around discussing mental health issues is beginning to erode. And there are new, remote roles—for example "virtualists" or "patient flow experts"—that experienced staff are well-suited for, turning retirement into a retention opportunity. 

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Participants in our sessions acknowledged there will be (at least) two workforce "must-dos" in early 2021: hardwiring any positive workforce changes from the pandemic into day-to-day operations and redefining the employee-employer compact to prevent any additional staff turnover, disengagement, and burnout.

3. Just like that, 2020 made health equity a real strategic priority

The tenor of the conversation around health equity—which encompasses things such as the social determinants of health, racial disparities, and root cause inequity drivers—was substantially different even just one year ago. During our international CEO roundtables on non-clinical care in early 2019, the predominant stance providers took was that this work was absolutely a priority, but limited progress could be made until policy or payment evolved.

That changed in 2020. Covid-19 exposed systemic inequalities and minority and vulnerable groups continue to be disproportionally affected by the disease. Health system executives in all three CEO sessions said they are more eager to assume a larger role in driving local community impact to better support vulnerable groups during and after the pandemic. The onus is now on policy makers to catch up with the progress providers have made.

And apart from the pandemic, last year brought an international outcry against systemic racism in the wake of George Floyd's death. This exposure forced executives to internalize the fact that that racism is a health care issue and to elevate it as an up-at-night health system problem.

But it's critical to note that these shifts signal a door opening rather than us reaching any sort of finish line. In the words of one session attendee from Ontario, Canada, the hard work now is to "go out and self-actualize."

4. All health systems are prioritizing virtual care, but they are going about it in two different ways

Virtual care is here to stay, but not at the levels we saw at the peak of wave one. We spoke at length about telehealth in the CEO summits, covering the "digital divide," telehealth reimbursement, chaotic virtual visit workflows, and cultural aversion to change. For the last point, we asked, "How are you prioritizing telehealth in your organizations?" To our surprise, members self-sorted into two camps.

In the first camp were those CEOs who have created a single symbolic, top-down, system-wide target to signal that virtual care is here to stay. These CEOs told us that they didn't necessarily expect clinicians to meet these targets, and that they felt confident that more specific and realistic targets would be agreed upon later. The job to accomplish here was signaling virtual care's permanence from the top.

In the second camp were CEOs who are leaving it to clinicians and service line leaders to craft multiple specific, bottom-up virtual visit targets for each sub-specialty. These CEOs told us that what clinicians needed was ownership in charting the system's path, not a signal to follow. The job to accomplish here was engaging clinicians at the outset.

At the end of the day, the best immediate option is going to be the one that works for you given your current telehealth uptake and your clinicians' feelings towards it. But the group was able to agree on the fact that at some point, democratization of telehealth targets will be necessary.

5. In the wake of booming surgical backlogs, systems are prioritizing 'value' as it's defined by the patient

One of the biggest disruptions from Covid-19 has been countries cancelling care to free up hospital space for Covid-19 patients, resulting in booming surgical and diagnostic screening backlogs. In New South Wales, Australia, some 95,000 people are waiting for scheduled procedures (up from 10,000 at the same time last year), and in England, the National Health Service (NHS) said the number of people waiting over 36 weeks for hospital treatment is six times higher than at the beginning of 2020.

Most of the attendees in our sessions are putting their ORs into overdrive and commissioning procedures to private providers to move through their waitlists. But some also said they are asking a simple question to reduce the total number of patients waiting: "Will this procedure actually provide value to the patient?" Elevating patient-defined value—the act of improving outcomes that matter to the patient while reducing cost—has always been a conversation, but we heard in the CEO sessions that systems around the world are now operationalizing it.

What this looks like in practice is removing patients from the wait list in favor of "high-value surgical alternatives" instead, based on what the patient's desired outcome of their treatment is. These alternatives include a range of non-surgical, preventive care options to help patients with non-urgent conditions—physiotherapy, palliative care, pain clinics, virtual rehab, social care, and so forth. These substitutions can either eliminate the need for a surgical procedure or be used as a short- to medium-term solution until the patient receives surgery.

As the pandemic's effects continue to be felt and backlogs remain long, these alternatives are likely to gain more traction in 2021 and potentially redefine how we think about "value" in a post-Covid world.