The Strategist's Tool Kit Part I

A Large & Angry Snail

Meet Gary. Normally Gary is a large but amiable snail who inhabits the cartoon world of SpongeBob Square Pants but today, for reasons I can't remember and you won't be interested in, Gary is a large and angry snail. Why introduce you to Gary?

In the early 2000's there was an online discussion about the impending effects of digital technology on media companies. One commentator shared the thought:

"It's like watching people being pursued by a large, angry snail. You can see the threat, there's plenty of time do something about it and yet you know there are going to be casualties".

It's a comic illustration relevant to the serious subject of strategy and digital health.

• Is your organization being pursued by a large, angry snail? If so, are you keeping ahead of the threat?
• Are our sick care systems being chased too? Yes... and the casualties manifest as an ever growing number of people who can't access or afford healthcare.

Many organizations are conscious that they are being pursued but the signs of an attack are subtle to begin with. The beginnings of an assault are gradual and not too painful and its a pain that's lost in the day to day running of an organization. Health (sick) care systems across the globe are busy and complex and they simply haven't changed fast enough to keep up with the challenge; the snail is here:

• Chronic diseases taking ‘immense and increasing toll on lives’, warns WHO | UN News

As touched upon in a previous edition, alternative, digitally-enabled systems are emerging; a new kind of snail:

• US Healthcare Braces For Tough Times As Disruptors March To Reform (forbes.com)

If the snail is subsuming our sick care systems, are those who serve these systems in danger of being subsumed too? Not in the immediate future. We may be entering a chapter of periodic crises that could hasten the pace of change but there are still huge amounts of money being invested to prop up these gargantuan systems. More money isn't the answer but incumbent suppliers to our sick care systems will welcome such investment which can actually prevent change. Change is needed and change will happen; it's a matter of how and when.

Here is the digital health strategist's dilemma. Should you wrap your strategy around the trajectory of our sick care systems knowing that disruption isn't accommodated or should your strategy be based on a new dynamic that relies on accelerated change? Can you accommodate both?

It's not an easy dilemma to resolve and the answer will depend on your specific circumstance but in the following article, I hope to cover some fundamentals that apply no matter what your situation.

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Beyond The Snail

No one wants to become the victim of a large and angry snail but strategists who recognize the threat can work with a more positive agenda in healthcare.

For example:

• How can digital health help my organization deliver better care?
• How can digital health help my organization compete in a commercial arena?

For private sector organizations (and perhaps even those in the third and public sectors) both questions can go hand in hand.

Change: A Cultural Phenomenon

When I was in a research environment learning was inherent. In the 90s, every Thursday lunchtime at the Sanger Institute, in the ramshackle building before the genome campus was built, we gathered to eat our sandwiches whilst listening to a guest speaker. I heard incredible things that excited me and made me want to learn. One of my most striking memories was of a presentation from one of Sir John Sulston's former post docs who had just taken up employment with a start up called Affymetrix - this was the first time we had heard of microarrays and collectively, we were blown away. We left excited for the future and keen to be part of that ever changing landscape. We were hungry to learn and to innovate as we excitedly shared ideas at ever opportunity.

A work force which is keen to learn and change within a culture of innovation is a powerful thing but is very different to the necessarily process driven culture present in large organizations and in particular, healthcare organizations (see edition 2 of this newsletter). For many, change is uncomfortable and is often met with resistance but that snail doesn't stop for anyone or anything. Strategy has a key role to play in digital health-related change and there are two prerequisites to consider in most circumstances.

• Building knowledge about digital health and ensuring its potential benefits are known to your organization (and individuals).

• As a strategist working in healthcare you know you can't effect change alone. You need to include and affect others and so stakeholder mapping is essential.

Stakeholder Mapping

Let me touch upon something that isn't specific to digital health but is a key tool in any strategist's tool kit: Stakeholder mapping.

I was interviewed by an academic earlier this year who was exploring approaches to digital health adoption and in the ~100 interviews they had conducted I was apparently, only the second person to bring up the subject so it's worth a mention.

The creation of stakeholder maps can be invaluable ahead of strategy development, particularly in the field of digital health. Why is this?

• The development of a digital health service typically involves many different types of stakeholders.
• The adoption of digital health technology by an organization typically involves many decision makers and influencers both within and out with the organization.

A formal depiction of those who can influence your strategy and those who will be affected by it can be a revealing exercise. Illustration of the relationships between these parties and their roles (decision makers, influencers etc) in development and execution should consider both individuals and organizations; external and internal parties.

I prefer to work with a small team with copious amounts of coffee and a large sheet of paper to start the process and then transfer this into a graphic with draft text for review.

• As with any document, there should be version control as it should be formally updated on a periodic basis.
• You can record your stakeholders along with their potential influence on your strategy and their relationship to other parties of influence.
• You can describe the kinds of activity intended to influence your stakeholders.
• As with any strategy-related document, keep it concise.
• Don't be tempted to include any content you wouldn't be happy to share in a public forum but you may choose to keep a closely guarded copy with your own private thoughts!

In such circumstances I have also used a communication matrix where the means to influence (activities and content ideas) were matched against stakeholders (X axis) and outcomes (Y axis). For me, "Marcomms" (market communications) is the closest skill set required to influence a wide range of stakeholders whether internal or external.

One of my fondest memories re stakeholder mapping and influencing involved hiring a fairy tale castle at Loch Ness in 2010 (I think) to host an international meeting on what was to become digital health. All credit to my former employers (an agency of the Scottish government tasked with economic development) who supported what could be viewed as a risky proposal (any public sector organization is rightly concerned with how they spend tax payers money but they understood the timely opportunity to influence a wide range of stakeholders). In return, we drew an international audience from healthcare organizations, leading edge SMEs, corporates, academics and government to the North of Scotland to create a vision of digitally-enabled healthcare in 2020; a document that was distributed far and wide to put the North of Scotland firmly on the digital health map (in a time before we had heard the term digital health!). A region more typically associated with sheep, tartan and whisky bathed in the reflected credibility of a variety of key stakeholders who were influenced by the presence of other key influencers drawn to a unique setting to produce a leading edge vision of healthcare that was very much in keeping with the needs and skill sets of the region (delivering healthcare across a remote and sparsely populated landscape punctuated with urban centers).

Stakeholder influencing can take many forms but the invite list to our "Highland Fling" was based on a comprehensive stakeholder map.

There is much in the literature about stakeholder mapping but here are a few articles for those with an appetite for reading. There is good material in here but for me, the art is to keep everything concise, clear and simple as this is a key reference document.

• Mapping stakeholders associated with societal challenges: A Methodological Framework - ScienceDirect

• Stakeholder Engagement: Past, Present, and Future - Johanna Kujala, Sybille Sachs, Heta Leinonen, Anna Heikkinen, Daniel Laude, 2022 (sagepub.com)

• A framework for stakeholder identification in concept mapping and health research: a novel process and its application to older adult mobility and the built environment | BMC Public Health | Full Text (biomedcentral.com)

Understanding your stakeholders and how to influence them is key to successful strategy execution but if your strategy is designed to help your organization embrace digital health, there is more prep work to be done.

Learning & Dissemination Strategy

Are you just starting your journey into digital health or perhaps "you're there" and trying to keep up to speed. As an individual how do you do this? Perhaps you read articles and newsletters, attend conferences and exhibitions, talk to knowledgeable people?

It's a challenge on an individual basis but it's a greater and more complex challenge for an entire organization.

The majority of organizations don't have learning and dissemination (L&D) strategies. The consequences? It is presumed that relevant knowledge somehow accrues and spreads at the right time to the right people within an organization to inform decision making and support innovation. A dedicated digital health L&D strategy can provide competitive advantage (if you speak that language) or you can view it as essential aspect of helping your organization to deliver the most effective and cost effective healthcare possible.

L&D strategies can be simple and effective especially for small to medium sized organizations. They become more challenging in large organizations with physically distant locations; a stakeholder map can be a useful tool in designing more sophisticated L&D strategy. Whatever your circumstance, there are several fundamental aspects to a learning and dissemination strategy.

• Who will be learning?
• Why?
• How will this be achieved?
• How is this disseminated?

Perhaps the most important point is "Why?".

"We are a healthcare/life science organization and digital health seems important so we better get up to speed" might be a common view but from a strategic perspective, it's not a helpful answer!

Answer the "why" with reference to your organizational objectives and you'll find your strategy becomes more effective accompanied by more buy in from your internal stakeholders.

For those at the start of their learning journey the challenge is "you don't know what you don't know" and given digital health is so broad, it might pay to bring in expertise to help guide your L&D efforts. That said, some organizations have developed deep expertise in particular aspects at the expense of their knowledge of the wider field which can be limiting. L&D strategies in both of these circumstances might not look too dissimilar.

Developing L&D Strategy For Digital Health

How do you develop an L&D strategy for digital health? This is very much dependent on the nature of your organization, it's size, its objectives and its familiarity with digital health but here are a few basic components that could be worked into an L&D strategy.

• Conferences: A coordinated approach to conference attendance and subsequent communication of associated learning.
• Formal learning: Education and training courses.
• Seminars: Presentations from internal and external guest speakers.
• Scoping reports: The output from an exercise to categorize and explain elements of digital health and their relevance to an organization.
• Horizon scanning: Activity to detect innovation relevant to an organization's interests.
• Consultancy: An individual or "digital health unit" with sufficient expertise to provide input and assistance to the wider organization.

Some of these activities may already occur in your organization but that's very different to an agreed plan of coordinated activity that systematically helps your organization achieve its objectives.

There is a significant additional advantage to a well constructed L&D strategy for digital health that may not be immediately obvious: identification of skill gaps. An L&D strategy that aligns with your company objectives is not only likely to enhance innovation but to reveal the skills and capabilities that will be needed on your journey into digital health. HR is a key stakeholder; involve them in the earliest stages of creating such an L&D strategy.

Digital Transformation

Having heard the anecdote about the large angry snail the subject of digital transformation might spring to mind. The terms digital health and digital transformation mean different things but from my perspective they can overlap. Here's a nice example.

• In Scotland (my old stomping ground) the health board NHS 24 is tasked with delivering digital health services to the nation. It was interesting to see an advert for a board member to assist with their digital transformation. I have no insider knowledge but I presume that the workforce consisted of people who had worked in "traditional healthcare" and although they were delivering a range of digitally-enabled services, it has been decided that this workforce needed to become more able to embrace digital technology in every aspect of their work. Digital transformation is a process (supported by strategy) that can be applied to any organization (including those that operate in healthcare).

But I'm not a fan of digital transformation!

• Firstly, there is good evidence that digital transformation strategies have largely been ineffective. Why Digital Transformations Fail: Closing The $900 Billion Hole In Enterprise Strategy (forbes.com) Why Digital Transformations Are Failing (forbes.com)
• Secondly, a well crafted strategy to promote the organizational embrace of digital health can enable digital transformation. I would argue that the results from a well executed adoption strategy can be more transformative and tangible (measurable) than the outputs from efforts in digital transformation.

You may not share my opinion on digital transformation but perhaps you would agree that a strategy to enable the adoption of digital health technologies must be people-oriented.

Digital Transformation Is Not About Technology (hbr.org)

Organizations are populated by people who use technology and successful adoption strategy requires learning but also doing. Having covered the strategic challenges of learning and influencing, the subject of the next newsletter will look at the role of pilots, feasibility studies and risk management in scaling the adoption of digital health.

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So let me finish with a word about DNA Sequencing. I first experienced sequencing in the late 1980s in a leading edge laboratory in Oxford University. We used degradative sequencing (working out DNA sequences by removing one base pair at a time - not recommended). Soon after we adopted Sanger sequencing using radioactive tags (again - not recommended). We were delighted with a 100 base pair read. By the early 90s at the Sanger Centre, we were still using gel based electrophoresis but with fluorophore tags and automated detection - much safer but still manually intensive. We then introduced more automation into the process; chemistry, loading, reading, analysing, assembling. By the end of my time at the Sanger Institute (98) next generation sequencing was on its way and the first sequence of the human genome was approaching its final stages.

10 years of progress... in the life sciences.. in a research market.

Technology advances rapidly but it's human beings that enable it to be used effectively. Overlook either of these factors in the long term and that snail will be bearing down... but of course this article is about healthcare which moves at a snail's pace?

About:

• I became involved with high through sequencing at the Sanger Centre and then high throughout automation in the private sector. That delicate balance of man and machine is something that I've carried with me into digital health.
• I've worked in academia, the public sector and the private sector which has taught me much about people and culture.
• My journey into digital health started in 2008. My excitement and enthusiasm for digital health is still there but I've developed a pragmatic approach to strategy development in response to some of the dynamics evident in the sector, particularly in the chapter spanning 2020 onwards ; process, evidence and understanding is required.
• 2023 has seen a shakeout of innovators in the space. 2024 may well see a shakeout out of the investment community as well as deepening crises in healthcare provision. I don't get caught up in the hype that's characterized this fascinating space but offer a pragmatic and professional approach based on what can be the uncomfortable realities of the sector.