Healthcare organizations require astute handling of strategy implementation. The processes must be followed with a contingency plan in place for failed strategic objectives leading to the goal. Review
Stages of implementation planning.
It is also important to consider whether the new policy can be implemented effectively using existing organizational structures, managementsystems, and funding approaches or whether there is a need to establish a new structure designed to deliver the changed output.
Work Breakdown
This stage is a detailed analysis of the tasks generated by the implementation requirements of the policy. Political decision makers are likelyto establish important dates (milestones) for implementation, dates that may or may not be achievable. Then the implementing organizationmust get to work:
• Identifying the tasks to be performed, such as submitting a detailed budget, hiring personnel, finding office space, issuing rules andregulations, establishing advisory committees, and specifying reporting requirements
• Identifying the units and individuals responsible for each task and gaining their commitment to complete the task within a specific timeperiod
• Establishing reporting responsibilities for the status of each task
• Including coordination tasks as well as intradepartmental tasks
• Developing a master schedule and an estimated time of completion for the project along with mechanisms for monitoring progress
Depending on the complexity and urgency of the project, the project implementation staff may choose to use any one of a number of projectmanagement techniques and their associated software to show what the resulting project duration will be and whether the original target islikely to be met. If not, implementation planners may decide to undertake a number of efforts to “crash” the project in order to remain onschedule.1 This process works best when the estimate of how long an activity will take comes from the individual or team that will beresponsible for that activity. This encourages participants to make realistic estimates and then commit to meeting their own estimates. Forexample, the Obama administration shortened the testing period for the insurance exchanges and failed to have top-level oversight of theprocess to determine whether this mission-critical system was up to its assigned tasks.
Funding
Few proposals get considered without a cost figure attached; however, additional steps related to funding may need to be taken once thatfigure is approved. Congress authorizes many more initiatives than it funds. For example, in 1998, Congress passed and President Clintonsigned the Ricky Ray Hemophilia Relief Act, which authorized a compassionate payment of $100,000 to each hemophiliac infected between1982 and 1987 from contaminated blood products, or to their families if they had died. This was to compensate for lax government control ofthe blood supply. The authorization bill did not include the funding required, estimated to be $750 million. Only after considerable effort byadvocacy groups was $75 million appropriated in fiscal year 2000, $100 million in fiscal year 2002, and $475 million in other years. By thetime the program was terminated in 2005, $559 million had been dispersed.
Risk Management
The Australian Guide to Preparing Implementation Plans states the following:
By understanding the potential risks which may affect the implementation of a policy measure, agencies can reduce the likelihood orconsequence of “unpleasant surprises” that may jeopardise the achievement of policy objectives.” (Cabinet Implementation Unit, 2006, p.23)
It suggests that likely risks include
• Unclear objectives and deliverables
• Unrealistic schedules
• Shortages of key resources—funds, people, equipment
• Lack of infrastructure and supports
• Lack of agency internal capacity
Whatever the risk, the planning process needs to assess the likelihood that it will occur, its severity and impact, how to mitigate it, and who isresponsible for preventive measures. It also needs to address monitoring and how to initiate any needed actions. In situations of highuncertainty and high impact, such as national security intelligence, analysts are now required to report their estimates of their certaintyregarding their findings.
One way for implementers to ensure that they will be able to respond to changing conditions is to keep the planning flexible. How does a planstay flexible?
• By not getting too detailed too early
• By not planning to use the available resources up to their limit
• By checking in with all implementers from time to time to see if anything has changed
• By having the periodic reviews to allow other parts of the plan to adjust to the “as built” changes that naturally occur
• By making sure the staff knows from the start that there will probably be changes
This does not mean that the planning is not complete. However, it does mean that there are contingencies built in and that the people on thejob are prepared to respond to unexpected situations as they arise.
Stakeholder Engagement
Implementation must include a review of the stakeholders, including the following:
• Who needs to be kept informed?
• Who needs to participate in what detailed planning activities?
• Who can be an opinion leader or champion of the program?
• Who needs further training and motivation?
• Who can be an enabler?
• Who can be a blocker and needs to be co-opted?
Then, as Table 13-1 illustrates, implementation planners must identify the type of commitment needed from the implementationstakeholder, how to secure it, key messages that need to be delivered, and who is responsible for the relationship. Decisions about how todeliver the message and maintain the relationship follow. Should it be delivered personally, by email, through the media, through arepresentative, and so on? After those coordination and communication tasks are identified, they can be scheduled and assigned to someone.
It often is best to approach this work with stakeholders as meaningful consultation and collaboration. This can make initial implementationeasier because stakeholders who feel that their ideas have been considered and their concerns addressed are less likely to try to subvert theprocess. Chances of success over time are greater if the people and organizations affected by the project recognize its value and are investedin its success. There will be times, though, when an implementing agency is given a mandate to implement a policy change on a specifictimeline over the objections of important stakeholders, and this may force the implementation planners to develop a policy for “stakeholdermanagement”—a term that is in disfavor but may be apt in such circumstances.
You may recall from discussions of evaluating political feasibility that most techniques involve collecting information from stakeholders. That is why the most popular framework for determining political feasibility is called “stakeholder analysis.” Political feasibility inquiries can yielda lot of information that can be very important during the implementation process. If Delphi processes, key informant interviews, or otherstakeholder outreach efforts were part of a feasibility evaluation prior to policy adoption, then implementers should review that material.Even if they feel they know the material, it could be helpful to turn to it with a fresh eye. A stake-holder concern that was not enough toprevent a policy’s adoption, for example, could frustrate or even derail that same policy’s implementation. Implementers might also consideremploying such processes after the fact as part of their stakeholder engagement practices.
