In the first of this two-part series, Director quizzed me on exactly what innovation strategy means, in concrete terms, not buzzwords. In this second part, I found out what Director knows about "the service line disconnect"—and why it is getting in the way of health system success when it comes to not just innovation strategy, but a wide range of ambitious system goals.
Amanda Berra: When last we talked, your questions about what is happening in innovation strategy at the system level with innovation were all premised on the idea that there is a gap between that activity, and what service line leaders are doing, thinking, and know about in their day-to-day closer to the front lines of care delivery. Can you explain more about this? What does the disconnect consist of, and why is it there?
Megan Director: Well, in general, service line leaders are not often brought into executive strategy decisions, even if it is about things that impact their day-to-day. For example, when CMS first put heart failure readmissions penalties into place, and system executives realized it could hit their bottom line, they started developing readmissions reduction task forces. But CV teams had already been working on this. So, you started to see a duplication in efforts because the system-level leaders were thinking about their system strategic plan, but not aligning it with the existing strategic plan of the service lines, and not bringing them into the relevant conversations.
Berra: Why do you think service line leaders were not invited to those conversations?
Director: Maybe because traditionally the service line leader used to be thought of as more of a clinical and operations role, and not as much strategy. Over the years, these leaders have become more strategic in nature as service lines are becoming more important to the health system. But the leaders themselves still don't always have a seat at the table.
This "service line disconnect" shows up in a lot of areas, including growth and business development, care variation reduction work, and of course, innovation. It's why innovation has been thought of as happening at the system level without connecting the dots to what service lines are already doing to innovate care models to meet their own strategic goals.
Berra: OK, let's be very concrete about this. In a typical service line, is there a service line strategic plan? And if yes, how does it relate to the system-wide strategic plan?
Director: Yes, there should be service line strategic plans in place at every system. In fact, that's part of how we define, within Advisory Board research, what needs to exist in order to call something "a service line"—there needs to be (1) that strategic plan, (2) dedicated leadership, and (3) some authority over budget to even qualify. But when it comes to service line strategic plans, we often see a disconnect between the plan for the system and how it cascades down to the clinical service lines.
Berra: Is part of the problem you're highlighting the fact that the plan tends to cascade DOWN, versus cascading UP (if you can overlook the metaphor problems with that)?
Director: In a way, yes. Because ideally, it should be a combination of both. System strategy leaders need to set the goals and general direction for their service lines, but they should be incorporating bottom-up intel gathering from the service line level to do so.
I would recommend three phases. First, strategy leaders should engage service line leaders on challenges, opportunities, and priorities. From there, the executives and planning team can define system-wide goals for the service line. And in that third phase, the planning team should be partnering with service lines to cascade system goals into meaningful service line opportunities. Then the service lines are responsible for building the plans to actually execute on these goals and objectives.
But that process often doesn't happen. It's too often top-down, and the service lines are left to figure it out on their own.
As for innovation, whether it's in the official system strategic plan or not, service line leaders may not know about it, or factor it into what they think of as their main concern, which is how they can solve problems—usually by getting scrappy and figuring out how they are going evolve, with or without system input.
Berra: In the spirit of scrappiness, you said something interesting a second ago about how service line leaders are already innovating. Can you explain how, if at all, service line leaders are thinking about emerging technology for hitting the goals that they know they have for the service line? I'm not talking about traditional clinical tech, like imaging or implantable devices—more, the types of tech that a system innovation strategy would be working to pull in, like consumer-facing digital solutions, AI, and things like that. Where does that show up in system service line leaders' work?
Director: In service lines, innovation has traditionally been about widgets and gadgets—like medical devices that we use in procedures. Service line leaders had to evaluate new tech in a reactive way, because their physicians or vendors would bring it to their desk, and they had to figure out whether or not to invest in that new patient care innovation.
But when it comes to digital tools and apps, often service line leaders don't feel empowered because that kind of contracting seems like a system-level decision.
Consider EHRs. Service line leaders have limited influence here. The system selects and forms partnerships with EHR vendors, telemedicine platforms, maybe startups that are developing new digital tech.
But excluding service line leaders is a big loss for the system because those leaders understand operationally how that solution will (or won't) work with physicians and workflows, and also whether and how it will help achieve service line goals. It's a sniff test for will this thing that sounds good actually work in practice—and is it something we need? If you don't get that perspective, you can really miss out on very valuable information about what is worth pursuing or not.
Berra: That's actually something we saw in the innovation research too. The programs we ended up profiling had staff that viewed talking with service line and other operational-leader type stakeholders as a core part of their role. I'm talking hours and hours every month in meetings with clinical leaders, asking them "what problems do you have" and talking about where and how emerging tech might help, and also sharing with them "here are some possibilities and new tech and new partnerships we are thinking about" and getting their feedback. It's obvious that that’s a better way for a system innovation team to be an asset to the system.
But my concern as I'm hearing you, is that what many of these innovation leaders told me they do all day, doesn't sound like it's common in your experience working with service line leaders. They say they're not having conversations like that. What gives?
Director: I don't know. But I will tell you that in the service line strategy planning workshops I have been doing lately, where we bring together service line leaders and strategy leaders, you can see a lot of untapped potential. The service line leaders are coming up with fantastic ideas when they are told, as part of the exercise, to think hypothetically and outside the box about how strategy problems in the service line could be solved, and what solutions they would recommend for the stakeholders they work with. For example, we often do a stakeholder analysis for patients, physicians, and payers in the market. During this, the service line leaders are coming up with digital technology, portals, innovative solutions to meet the needs of multiple stakeholders, because service line leaders have that uniquely broad perspective based on where they sit. At the end of the workshop, the strategy leader ends up taking away a lot of these ideas as a short list of the higher value opportunities to leverage tech for service line goals.
It's all great—but, it's clear to me that these people have not had these conversations in other forums yet. The service line leaders are saying things like, "Why don't we have x to help with patient journey, or help with patient outreach" while the strategy leaders are asking, "Why is this the first time we are thinking about this?"
Berra: Well, one thing I notice about what you're saying is that it is the STRATEGY leader getting pulled into these conversations, not the INNOVATION leader. So, maybe we're looking at the market reality that there are still plenty of systems that do not have a dedicated innovation team yet. And even if there is a team, it may not yet be plugged into all these stakeholder conversations.
Berra: OK, different question. It makes sense to say, "System-level executives should deal service line leaders in to find opportunities." But, in theory, one of the benefits of doing innovation centrally, at the system level, is that you can spot things that would apply across service lines—so that the system doesn't end up with a lot of fragmentation and a billion little pilots and different apps and no unified platform.
Knowing that you're personally deepest in CV, but you also spend a lot of time talking "pan service lines," what do you think about that and innovation? When you hear service line leaders talking about opportunities to use emerging tech, does it seem like things that would span across all the major clinical service lines? Or does it sound like CV needs CV things, and cancer care needs cancer care things, or what?
Director: Great question. This gets back to the earlier issue about why there might be a discontent between system-level initiatives and service-line realities. It used to be that transformative catalysts for care innovation were external pushes, especially new Medicare requirements, often in disease-specific ways. Think mandatory episodic bundles that started with orthopedic procedures. Now we are seeing them in oncology. As a result, these teams are thinking in their own worlds about how to manage complex or chronic patients across the continuum of care, and so innovation happened in a siloed way.
But really, it doesn't matter what the disease state is—there are common things you can do to better manage these patient populations, and probably huge opportunities to solve larger programs. That means siloed problem solving is not the right answer.
So innovation leaders would do well to bring the service line leaders together to talk about these issues; there are common problems they could find that would span clinical areas. Especially with goals like engagement and patient management across the continuum, or managing patients at home. Yes, there are nuances in what you do or say to that patient, but the concept and strategies for reducing readmissions or managing complex patients will be the same, so there should be a lot of opportunity.
Now to be clear, you don't need every service line leader in every innovation discussion, that isn't feasible. But you need a forum for service line leaders to gather together and share ideas and prioritize challenges, because that is where you will find the most scale for innovations to invest in.
Berra: Let’s throw in the venture capitalist’s favorite question—with your pan service line view, what kinds of problems would you bet on, as areas that are ripe for tech to solve—or, specific tech that you hear enthusiasm about among service line leaders?
Director: A lot of what is popping is patient activation and engagement, and increasing access to patients across the continuum to better manage overall care. On the front end, getting patients in the door. With Covid-19, it's about patients being hesitant to come in and programs need better ways to communicate with them to let them know how to approach a visit, where to get the care why they should be coming in. But, it's not just a Covid-19 issue, this will be around long after the pandemic is hopefully behind us. Think how many patients are not getting screenings like mammography or CV if they are at risk.
Systems need better ways to engage with patients, or prospective patients, at scale to risk-stratify, triage, identify, and invite patients in the door. If you can be the best at doing that in your market that is how you will get patients in. A lot of folks are talking about that.
Berra: Is it the system that needs to have that interface—an app, I guess? Or is it primary care? I feel like there’s been a lot written about how some hospital and system apps are not well used—and it almost seems like the primary care practice, or maybe a medical specialist, is the one who needs to have that ongoing relationship.
Director: Agreed—ultimately for many hospitals and systems, they’re still predominantly about sick care. On the well care end, it’s those general practitioners or others who have a longitudinal relationship with patients who make more sense as a ‘front door’ of ongoing communication and care.
Berra: Takeaway for innovation strategists and service line leaders alike being: Consider your primary care referral channels, and what their digital relationship with patients is like!