Read the following article:

Community Health Center Efficiency: The Role of Grant Revenues in Health Center Efficiency 

Complete a detailed case study analysis of the given case, using the process described in Analyzing Strategic Health Care Cases in your course textbook Strategic Management of Health Care Organizations.

Your completed case study analysis report will include the following sections:

Executive summary

Key issues                        

Situational analysis

Strategy formulation

Recommendation

Implementation strategies

Benchmarks for success and contingency plans

Resource 1

Analyzing Strategic Health Care Cases

“Case studies provide low-risk experience.”

How do students of management gain experience in strategic thinking and making strategic decisions in health care organizations? One way is to work their way up the organization – holding a variety of positions, observing others, experimenting as they develop their decision-making skills – as they deal with issues and develop strategies. Then, when the opportunity presents itself, they combine what they have learned from others and their own management philosophy, and do the best they can. Unfortunately, learning chiefly through experience may be risky in rapidly changing environments and in the often unique situations that health care managers and leaders face.

Hospitals, HMOs, long-term care facilities, public health and other health services organizations prefer to trust important decision making to accomplished managers and leaders. Case studies have been used successfully as a surrogate method to provide aspiring managers and leaders with experience in strategic thinking, strategic planning, and making decisions without undertaking substantive risk. The best case studies contain real situations actually faced by managers and leaders in health care organizations and are documented in a way that makes them useful in providing experience for future strategic decision makers. Because many instructors in strategic management classes use case studies to provide future health care decision makers experience in making strategic decisions, this resource has been included, not to prescribe how cases should always be solved, but to offer some initial direction on how to surface and address the real issues.

An Overview of Case Analysis

Case analysis provides health care students with an exciting opportunity to act in the role of a key decision maker. From hospitals to community blood centers to physicians’ offices, students have the chance to learn about a variety of health and medical organizations and to practice decision-making skills through analyzing cases.

The decisions required to “solve” cases represent a wide range of complexity, so that no two cases are addressed in exactly the same manner. However, the strategic thinking maps presented in this text provide frameworks to aid in strategically thinking about case issues. The fundamental task of the case analyst is to make decisions that will serve as a map to guide the organization into the future. Therefore, most case instructors will expect a comprehensive plan for the organization that addresses relevant current issues and provides a viable and reasonably complete strategy for the future. To achieve this goal, the case analyst typically should:

Summarize the key issues.

Analyze the situation.

Develop an organizational strategy.

Develop an implementation plan.

Set benchmarks to measure success.

These categories represent the major elements of strategy development and make appropriate section headings for a case analysis written report or presentation. First, using the strategic thinking map presented in Chapter 1 (Exhibit 1–1), it is important to do some serious strategic thinking about the external environment of the organization – the political/legal, economic, social/cultural, technological, and competitive situations faced by the case characters. After gathering information about the issues in the general environment, health care system, and the service area, the service area competitors should be assessed. Next, it is important to relate the internal resources, competencies, and capabilities of the organization to external conditions, which will require a thorough and objective analysis of the competitively relevant strengths and weaknesses. The value chain provides a useful tool for uncovering these strengths and weaknesses. These strengths and weaknesses must be evaluated according to their potential to create competitive advantages or disadvantages for the organization. External issues and the organization’s competitive advantages and disadvantages provide the basis for strategy formulation. In addition, to create the strategy for a health care organization, understanding its unique mission, vision, values, and strategic goals (directional strategies) is necessary.

Once the situational analysis is complete, strategic alternatives can be generated as possible solutions to the issues identified in the case. Consideration must be given to the feasible adaptive strategies, market entry/exit strategies, and competitive strategies that provide the means for achieving the organization’s mission and goals and lead to the accomplishment of its vision. The effectiveness of the chosen alternative for each type of strategy must be evaluated. In addition, attention must be given to the likely outcomes resulting from the different choices. After the evaluation, a recommendation needs to be made from among the alternatives.

Nothing will happen, of course, unless the strategy can be implemented. Therefore, the case analyst must address how the strategy will be carried out. The development of a practical implementation plan should include specific service delivery and support strategies and, where possible, action plans. These areas are important because they create value for the organization and translate strategy into organizational and individual actions – the work to be done.

Finally, the case analyst should consider how the success of the proposed strategy should be measured. Returning to the mission, vision, values, and goals will provide an initial measure of success. Other measures will include fit with the changing external environment, internal changes (development of competitive advantages and lessening of competitive disadvantages), and other more specific measures such as financial measures, market share, revenue growth, and so on.

Although the approach outlined here is logical, it is important to remember that a case should be approached and appreciated as a unique opportunity for problem solving. If everyone agrees that a case has only one solution – there’s only one right answer – then it is not a good decision-making aid, and rather than applying decision logic and learning from others, participants will simply rehash case facts. Moreover, managers in health care organizations rarely face problems where the solution is obvious to everyone. This does not mean that there are no good and bad answers or solutions in case analysis; some are better than others on the basis of the logic presented. Sometimes the issues presented in a case are not even problems (defined as a negative occurrence that needs to be addressed). Often the greatest challenge facing an organization is recognizing and acting on an opportunity rather than solving a problem. The evaluation of a case analysis is often based more on the approach and logic employed than the precise recommendation offered.

Cases, Strategic Management, and Health Care Organizations

Cases add realism that is impossible to achieve in traditional lecture classes. Realism results from the essential nature of cases, although students may complain that cases fail to provide all the information necessary for decision making. The complaint is valid because cases rarely provide everything that is needed; however, decision makers in health care organizations rarely have all the information they want or need when they face decisions. Risks must be taken in case analysis just as in actual decision making.

Risk Taking in Case Analysis

Any decision about the future involves uncertainty. Decision making under conditions of uncertainty requires that means be devised for dealing with the risks faced by leaders. Cases are valuable aids in this area because they allow the analysts to practice making decisions in low-risk environments. Decisions in a poor case analysis may be embarrassing, but at least they will not result in the closure of a hospital or medical practice. At the same time, the lessons learned by solving cases and participating in discussions will begin to build problem-solving skills.

Solving Case Problems

Solving a case is much like solving any problem. First, information is gathered and issues are defined; the competitive situation is analyzed; alternatives are generated, evaluated, selected, and implemented. Although the person solving the case seldom has the chance to implement a decision, he or she should always keep in mind that recommendations must be tempered by the limitations imposed on the organization in terms of its resources, competencies, and capabilities (although strategies to improve these areas may be required). As the success or failure of the recommendation is analyzed, lessons are learned that can be applied to future decision making.

Alternative Perspectives: Passion or Objectivity

Different hypothetical roles can be assumed when analyzing cases. Some prefer to think of themselves as a passionate advocate for a particular course of action while others prefer to observe the case from the detached objectivity of a consultant who has been employed by the organization to solve a problem.

Either the advocate or the consultant perspective may be assumed, but the first offers some unique advantages. To answer the questions from the advocate’s perspective, understanding what is inside the decision maker’s head – to feel the excitement and fear of doing new and innovative things in the dynamic and complex health care system – is important. The passion and frustration of the advocate suggest why some case analysts prefer to assume the objective posture of a consultant. Not being in the front line can sometimes suggest alternatives that cannot be seen by those directly involved in making payroll and paying the bills. The consultant can more easily play the devil’s advocate and point out how actions are at odds with current theory. Although the fun and excitement of case analysis is enhanced by assuming the decision maker’s role of an influential advocate with a specific strategy in mind, the options might be expanded through the more objective and detached outlook of an outsider. There are no absolutely correct or incorrect answers to complex cases. The most important lesson is to learn problem-solving and strategic management skills.

Reading the Case

Effective case analysis begins with data collection. This means carefully reading the case, re-reading it, and sometimes reading it yet again. Rarely can anyone absorb enough information from the initial reading of a comprehensive case to adequately solve it. From the very first reading of the case, the analyst should start to list the external issues and the organization’s internal strengths and weaknesses. For example, when a significant issue is discovered it should be marked for more detailed examination. “Is the issue financial? Do the primary issues appear to be those of human resources, capital investment, or marketing?” Perhaps there are few, if any, apparent issues with negative consequences. The strategic issue facing the organization may be one to be exploited or it may have both positive and negative aspects. For example, health insurance reform has created some interesting positive and negative consequences for many health care organizations.

Listing the possible strengths and weaknesses in the initial reading provides some perspective concerning the organization’s resources, competencies, and capabilities. This list will provide a basis for further investigation and provide a guide for additional information gathering. Once the situation has been reviewed, a better evaluation of the issues facing the organization can be made. An effective way of summarizing the results is through the use of a SWOT analysis (refer to Chapter 7, Exhibit 7–3) or an external/internal strategy matrix (refer to Chapter 7, Exhibit 7–4), which shows the long- and short-term competitive advantages and disadvantages as well as external issues.

Gathering Information

The information required to successfully analyze a case comes in two forms. The first type of information is given as part of the case and customarily includes history of the organization, its organizational structure, its management, and its financial condition. Gathering this information is relatively easy because the author of the case has typically done the work.

A second type of information is “obtainable.” This information is not provided in the case or by the instructor but is available from secondary sources in the library, familiar magazines and other publications, as well as online. Obtainable secondary information helps with understanding the nature of the service category, the competition, and even some managers, past and present, who may have made an impact on the service category.

If the case does not include service category information or competitor information, the instructor may expect the class to do some detective work before proceeding. Students should investigate to find out what is happening in the service category and learn enough about trends to position the problems discussed in the case in a broader health care context. The culture of the organization or the style of the chief executive officer may constitute relevant information (though some instructors do not want students to investigate beyond the date of the case or to gather additional service category data; therefore, students must ask the instructor’s preference). Be sure to consult the professor prior to analyzing your first case. Furthermore, if the first thing that students do after receiving a case assignment is to go to the web to search what the company did in the situation presented, they are much less likely to be able to develop innovative solutions. The assumption is that the company did the right thing, when in fact if the company had a chance to do it all over again, a completely different strategy might have been pursued. Good cases, as in life, have a number of options that have to be weighed, and a number of reasonable alternatives evaluated before drawing a defensible solution.

Case Analysis Using the Strategic Thinking Maps

The strategic thinking maps presented in this text provide a means of thinking through strategic management issues and serve as road maps to case analysis. They are useful for analyzing cases and succinctly presenting strategic management decisions in written reports and presentations. The following discussion provides some tips for using the strategic thinking maps in each of the major elements of case analysis – surfacing the issues, situational analysis, development of the strategy, and development of the implementation plan.

Tips on Surfacing the Issues

The discussion and questions presented in the “Managing Strategic Momentum” section of each chapter are designed to bring attention to present and potential issues. In case analysis, issues include not only problems that need to be rectified, but also situations where things may be working well but improvements are possible. The problem may actually be an opportunity that can be capitalized on if the organization acts consciously and decisively. With careful analysis, patterns can be detected and discrepancies between what actually is and what ought to be become more apparent. In other words, fundamental issues, not mere symptoms, begin to emerge.

Problems vs. Symptoms

It is important to realize that the things observed in an organization and reported in a case may not be the real or essential issues. Often what analysts observe are the symptoms of more serious core problems. For example, increasing interest rates and cash-flow discrepancies appear to be problems in many case analyses. In reality, the issue is the fundamental absence of adequate financial planning. The lack of planning simply manifests as a cash-flow problem and rising interest rates certainly complicate cash flow.

Frequently, hospitals conclude that they have a marketing problem when bed occupancy rates decline. Someone may suggest that the marketing department is not doing a good job of convincing physicians to use the hospital or that the hospital is not spending enough on advertising. The real issue, however, might be fundamental changes in the demographics of the market area or an outdated services mix that no amount of advertising will overcome. In organizations as complex as health care, problems may have more than a single cause, so the analyst must not be overly confident when a single, simple reason is isolated. In fact, the suggestion of a simple solution should increase rather than decrease skepticism.

Using Tools

Identifying key issues requires that information be carefully examined and analyzed. Often, quantitative tools are helpful. Financial ratio analysis of the exhibits included in the case will sometimes be helpful in the identification of the real problems. In arriving at the final determination of core problems, the analyst should try not to slip into “paralysis by analysis” and waste more time than is necessary on identifying problems. At the same time, premature judgments must be avoided because then real issues may be missed. One general guideline is that when research and analysis cease to generate surprises, the analyst can feel relatively, though not absolutely, sure that adequate research has been conducted and the key issues have been identified.

Check Facts

The issue discovery process should not become myopic. For example, there may be a tendency on the part of individuals interested and experienced in accounting and finance to see all problems in terms of accounting and finance, whereas a physician approaching the same case will likely focus on the medical implications. This approach is too limited a view for effective strategic decision makers. Strategic analysis effectively transcends a single function. Insistence on approaching case analysis exclusively from the viewpoint of the analyst’s expertise and training is not likely to produce an accurate overall picture of the situation facing the organization; nor is this approach likely to improve the organization’s performance.

Information, either given or obtained, must never be accepted at face value. If a CEO states that the hospital delivers outstanding quality care, it should not be accepted as a statement of fact without some thought. For example, a character in the case may voice an opinion that is not grounded in fact. The ratios on a long-term care facility’s financial statements may look strange, but are they? Before jumping to such a conclusion, analysts should look at the financial ratios in a historical perspective. Even better, they should look at the history (as well as similar ratios) of other long-term care facilities of the same size during the same time period.

Relevant Issues

Once the issues are identified, they must be precisely stated and their selection defended. The best defense for the selection of the key issues is the dataset used to guide the issue discovery process. The reasons for selection of the issues should be briefly and specifically summarized along with the supportive information on which judgments have been based. The issue statement stage is not the time for solutions. Focusing on solutions at this point will reduce the impact of the issue statement. If the role of consultant has been assumed, the issue statement must be convincing, precise, and logical to the client organization, or credibility will be reduced. If the role of the strategic advocator has been selected, the student must be equally convincing and precise. The strategic decision maker should be as certain as possible that the correct issues have been identified to pursue the appropriate alternatives.

The statement of the issues should relate only to those areas of strategy and operations where actions have a chance of producing results. The results may be either increasing gains or cutting potential losses. Long- and short-range aspects of issues should be delineated. In strategic analysis the emphasis is on long-range issues rather than merely handling emergencies and holding things together. However, in some situations, immediate problems have to be solved and then a strategy developed to avoid similar situations in the future (combination strategy).

It is important for students to keep in mind that most strategic decision makers can deal with only a limited number of issues at a single time. Therefore, identify key result areas that will have the greatest positive impact on organizational performance.

Tips on Analyzing the Situation

Situational analysis is one of the most important steps in analyzing a case. In most instances instructors will expect comprehensive external and internal analyses. For external analysis, the case analyst may want to use and present a variety of tools including a trend analysis, stakeholder analysis, the development of a scenario, and service area competitive analysis. Whatever method is used, a clear picture and assessment of the external environment should be presented. Chapters 2 and 3 provide strategic thinking maps for assessing the external environment.

For the internal analysis, it is important that the case analyst understands the strengths and weaknesses of the organization in terms of its resources, competencies, and capabilities. Therefore, the case analyst may want to use the value chain, as discussed in Chapter 4, to map resources, competencies, and capabilities and assess their strategic relevance using the criteria of value, rareness, imitability, and sustainability.

Understanding the mission is a good starting point to assess the directional strategies. If a mission statement is included in the case, the analyst should ask “Does it serve the purpose of communicating to the public why the organization exists? Does it provide employees with a genuine statement of what the organization is all about?” In addition, the other directional strategies (vision, values, and strategic goals) should be evaluated as to their appropriateness to the organization and its environment. The vision and goals provide a profile of the future and targets to focus organizational actions. The case may (or may not) indicate what the health care organization plans to achieve in the next year and where it hopes to be in three years, or even in five years. As with mission statements, if the vision and goals are not explicitly stated, there is a need to speculate about them because they will be the standards against which the success or failure of a particular strategy will be evaluated. Moreover, because strategic planning is futuristic and no one can predict the future with complete accuracy, vision and goals should always be adaptable to the changing conditions taking place in the organization and in the service category. An organization may be forced to face a major strategic problem simply because it was unwilling to alter its vision and goals in light of changing conditions.

Tips on Formulating the Strategy

After the situational analysis, a recommended course of action – the strategy – must be developed. Thus, adaptive, market entry/exit, and competitive strategies for the organization must be recommended and defended. Exhibit 6–4 provides a strategic thinking map depicting the various alternatives for each of the types of strategy in the strategy formulation process.

Effective Alternatives

If obtaining and organizing information have been done well, the generation of strategic alternatives will be a challenging yet attainable task. Good alternatives possess specific characteristics:

They should be practical or no one will seriously consider them. Alternative courses of action that are too theoretical or abstract to be understood by those who have to accomplish them are not useful.

Alternatives should be specific.

Alternatives should be related to the key issue they are intended to address. If the strategic alternatives generated do not directly address key issues, the analyst should ask how important the issues are to the case analysis; rethinking the issues may be required.

Alternatives should be implementable. An implementable alternative is one that can be reasonably accomplished within the constraints of the financial and human resources available to the organization.

Alternatives should be able to be placed into action in a relatively short period of time. If it takes too long to implement a proposed solution, it is likely that the momentum of the recommended action will be lost.

Alternative Evaluation

Alternatives should be evaluated according to both quantitative and qualitative criteria. Financial analysis provides one basis for examining the impact of different courses of action. However, a good alternative course of action is more than merely the one with the highest payoff. It may be that the culture of the organization cannot accommodate some of the more financially promising alternative courses of action. For the adaptive strategies, one or more of the decision-making tools discussed in Chapter 7 should be used – external/internal strategy matrix, PLC analysis, BCG portfolio analysis, extended portfolio matrix analysis, SPACE analysis, or program evaluation. For the market entry/exit and competitive strategies, matching the external conditions appropriate for the strategies with the internal requirements of the strategies as discussed in the text, alongside the internal strengths and weaknesses and external conditions described in the case, provides a basis for selecting and defending these strategies (Chapter 7).

The case analyst should be able to map the strategies selected in the strategy formulation process. Strategy maps similar to the one presented in Exhibit 7–25, an example for a long-term care organization, show the decision logic for each strategic initiative and provide an excellent overview of the strategy of the organization.

Tips on Developing Implementation Strategies

Once a strategic alternative has been selected, an action plan is required. Action planning moves the decision maker from the realm of strategy to operations. Now the question becomes, “How does the group accomplish the work in the most effective and efficient way possible?”

The task of case analysis does not require actual implementation; however, because the strategies must be implementable, it is necessary that thought be given to how each strategy would be put into action. Therefore, value-adding service delivery and support strategies must be developed as well as action plans. This process is a continuation of the linkage started in strategy formulation – the implementation strategies are the means to achieve the overall organizational strategies.

Each element of the value chain should be addressed, comparing the results of the internal analysis with the requirements of the selected strategy. Matching the present situation with the requirements of the strategy provides a basis to maintain the value chain element or change it to meet the needs of the strategy. Exhibits 8–9 and 9–7 provide templates for information instructors might expect for presenting the value-adding strategies. Exhibits 8–10 and 9–9 provide examples of completed templates for a skilled nursing facility.

Next, action plans for the major organizational units affected by the strategy should be developed. Objectives, action plans, and budgets should be addressed if enough detail is provided in the case. Finally, the responsibility for accomplishing the different groups of tasks must be clearly assigned to the appropriate individuals. Although this is not always possible in case analysis, it is important that consideration is given to how, in a real organization, the recommendations would be accomplished. If, in the process of thinking about how different activities will be completed, it becomes apparent that the organization lacks the resources or the structure to accomplish a recommendation, another approach should be proposed.

The process of developing action plans for important organizational units – whether a highly focused unit, such as a pharmacy, or a broadly focused unit, such as a hospital division for a health system – should not be neglected. Organizations sometimes spend large amounts of money and resources developing strategic plans only to discover that they are not prepared to implement them in an effective manner.

Making Recommendations

Making good recommendations is a critical aspect of successful case analysis. If recommendations are theoretically sound and justifiable, people will pay attention to them. If they are not, little is likely to result from all the work done to this point.

One effective method for presenting recommendations is to relate each one to organizational strengths. Or, if necessary, a recommendation may be related to addressing a weakness. If the organization has sufficient financial strength, the recommendations should highlight how each alternative will capitalize on the strong financial condition. If, on the other hand, the resources are limited, it will be important to avoid recommendations that rely on resources that are not available; a combination strategy to gain new resources might be recommended.

It will be particularly useful to ask the following questions when making recommendations:

Does the organization have the financial resources needed to make the recommendation work?

Does the organization have the personnel with the right skills to accomplish what will be required by each recommendation?

Does the organization have methods to monitor whether or not the recommendations are being accomplished?

Is the timing right to implement each recommendation? If not, when will the timing be right? Can the organization afford to wait?

Finalizing the Report

Preparation and presentation is the final activity in most case analyses. Although the form of the report may vary, the goal is the same – to summarize and communicate in an effective manner what the analysis has uncovered and what the organization should do.

Decision making is the intended result of the report. The analysis must be complete; but the emphasis should be on making the entire report brief enough to encourage people to read it and comprehensive enough to ensure that no major factors are overlooked – especially those that might adversely affect the decision. Therefore, charts and flow diagrams can be effective. In a brief outline, the important sections of a case analysis report include:

Executive summary – Usually one page, and rarely more than two pages, it functions as an abstract. Its purpose is to force the writer to carefully evaluate what is really important in all the accumulated facts and data. It is not an introduction (no company history, no re-statement of case facts, etc.). Include what the CEO would want to know: what is the issue, what are the recommended strategies (the hierarchy of strategies), how much will it cost. If he or she wants more information on any of the points in the Executive Summary, they should be discoverable in the Table of Contents to find the correct pages for more information.

Body of the case report

Key Issues: with the rationale for focusing on them.

Situational Analysis: results of the external analysis, service area competitor analysis, and internal analysis, as well as analysis of the directional strategies.

Strategy Formulation: feasible alternatives for directional, adaptive, market entry/exit, and competitive strategies.

Recommendation: analysis of the feasible alternatives, and which one or ones is/are recommended.

Implementation Strategies: service delivery and support strategies with linkage to the directional, adaptive, market entry/exit, and competitive strategies.

Benchmarks for Success and Contingency Plans: measures of success for the strategy and alternative plans if a major opportunity or threat is subject to change in the short run (contingency plan).

Conclusions

Case analysis is an art. There is no one precise way to accomplish the task, and the analysis has to be adapted to the case problem under review. The analyst must keep in mind that case analysis is a logical process that involves: (1) clearly defining strategic issues; (2) understanding the situation – the organization, service area/service category, and environment; (3) developing a strategy to enable the organization to accomplish its mission and vision; and (4) formulating an implementation plan.

The work of case analysis is not over until all these stages are completed. Often a formal written report or oral presentation of the recommendations is required. Case problems provide a unique opportunity to integrate all that students have learned about decision making and direct it toward issues faced by real organizations. It is an exciting way to gain experience with decision making. Students should take it seriously and develop their own systematic and defensible ways of solving management problems.