Building a Strategy Map for Health and Social Care Regulation: The Case of the Regulation and Quality Improvement Authority

Introduction

Core to the development of its strategic plan for 2009-2012, Northern Ireland's Regulation and Quality Improvement Authority (RQIA) built a Strategy Map and a supporting strategic performance management framework of objectives, initiatives, Key Performance Questions (KPQs) and Key Performance Initiatives (KPIs). Facilitated by the Advanced Performance Institute, the strategy and supporting Strategy Map were created through an iterative process. The early steps involved one-to-one interviews with board members followed by a dedicated workshop for the executive team and a joint workshop involving the board and executive team members: this led to the formulation of a draft Strategy Map. Refinements were made following an extensive consultation period with a broad range of stakeholder groups, including employees as well as service users and other service providers. This case describes the myriad benefits that RQIA has thus far achieved from deploying a Strategy Map and strategic performance management framework and explains some of the most significant challenges it has faced along the way.

About RQIA

Established in 2005, the Belfast-headquartered Regulation and Quality Improvement Authority (RQIA) is the health and social care regulator for Northern Ireland, which has a population of about 1.7 million. With about 150 staff and a budget of just over £7 million, RQIA monitors and inspects the safety, quality and availability of health and social care services. Commencing 2009 RQIA also assumed responsibility for a range of services for people with mental ill health or a learning disability.

RQIA'S Value Proposition

The organization's "reason for existence," is captured through a powerful value proposition that reads: "RQIA provides independent assurance about the quality, safety and availability of health and social care services in Northern Ireland, encourages continuous improvement in those services and safeguards the rights of service users." Unlike many such propositions (oftentimes called "mission" statements), this is not just a one-off endeavor which is thereafter forgotten. Rather, within RQIA this value proposition provides the central steer for the organization's strategic plan from 2009-2012 and, as we shall explain, serves as the anchor to the Strategy Map and accompanying strategic performance management framework that has been created to deliver the strategy.

Strategy Development

The project to develop the 2009-2012 strategic plan, and framework for its delivery began in October 2008 and was facilitated by the Advanced Performance Institute (API). Maurice Atkinson, RQIA's Director of Corporate Services, explains why API was chosen to support this effort. "During 2008 we began to look for an underpinning methodology that would inform, and provide rigor to the development of the new strategy," he says. "While completing a thorough scan of existing methodologies we became aware of API's value [or strategy] mapping approach through a conference presentation made by Bernard Marr [API's Chief Executive Officer]. In particular we were attracted by the fact that the methodology tied together the setting of strategic direction with performance measurement disciplines, both of which we believe to be of the utmost importance to the organization going forward." The Chairman of the Board, Dr Ian Carson was convinced that at this stage of the development of RQIA as an organization, "an exciting and innovative approach was necessary to create a new strategic agenda." Atkinson adds that the conviction that the API methodology would be appropriate for RQIA's needs was strengthened as a consequence of the Authority becoming aware of the successful work the consultancy has completed in strategy development and mapping at Northern Ireland's Belfast City Council.

Beginning the Process

Articulating the strategy and developing the map commenced with API conducting one-to-one interviews with non-executive and executive board members. These interviews focused onto three key questions. 1. Why does RQIA exist? 2. What are the vital things that RQIA must excel at to fulfill its role? 3. What are the underpinning enablers that RQIA must leverage in order to maximize value? The replies from the board members were fed-back collectively and anonymously for debate and discussion at a workshop for the executive team. The outcomes from these conversations then served as the basis for a further round of debate and discussion, this time within a workshop that jointly involved the executive team and corporate board. "Answering these questions proved both useful and challenging," says Atkinson. "Creating the time and space to complete this exercise really helped to provide a better sense of what we wanted to achieve strategically and by the end of the second workshop we had completed the first cut of the Strategy Map." Widespread Consultation The next steps saw the draft strategy and map go through an intensive development phase. With the executive team serving as a working, or steering, group, the strategy and map were discussed, reviewed and amended through a series of weekly meetings, engagement with staff and further involvement of board members. A formal consultation process with external stakeholders (such as service users, carers, members of the public and others that deliver services) was initiated, and included a range of public engagements throughout Northern Ireland. This process resulted in strong endorsements of the draft strategy from stakeholder groups.2 For example, 96% of those consulted agreed with the overall strategic direction for RQIA as presented in the Strategy Map. Furthermore, viewing the plan "on a single page" was seen as a clear way of showing RQIA's strategic direction. The outcome of the development and consultation phases, which Atkinson says were "very iterative, challenging and rewarding," was a finalized and approved strategy and map, both of which went live in 2009. Although the strategic plan is to 2012, provisions are in place to extend this to 2014 if thought appropriate (therefore extending over a five-year,as opposed to three-year timeframe).

The Strategy Map Described

RQIA's Strategy Map is shown in Figure 1. The map comprises four levels: 1. Value Proposition 2. Core activities 3. Value drivers 4. Resources

Value Proposition

At the apex of the map is RQIA's value proposition. which defines the value the organization delivers to stakeholders.

Core Activities

The value proposition is distilled into four core activities that RQIA deems to be critical for the successful delivery of its strategy. These core activities define both what the organization must focus on and what differentiates RQIA from other organizations. Each of these activities: "improving care," "informing the population," "safeguarding rights," and "influencing policy," has a single line description. For instance, "safeguarding rights," is described as: "we act to protect the rights of all people using health and social care services."

Value Drivers

To deliver to these activities, RQIA has identified nine "value drivers." These represent the activities, linked to RQIA's financial, physical and intangible resources which need to be in place to deliver the strategy. As depicted on the map, value drivers include "engage effectively with stakeholders," "value and develop our staff," and "use evidence and research to underpin all of our activities."

Resources

Finally, at the base of the Strategy Map RQIA has identified the resources that underpin its work and which must be managed effectively: identified resources include "organizational relationships," and

"information and communications technology infrastructure."

Strategic Performance Management Framework

Importantly, the Strategy Map is not the only component of RQIA's strategic performance management framework. Rather the map represents the highest level of a broader strategic performance management framework that describes and provides a roadmap as to what RQIA must do to successfully deliver its strategy. The framework is constructed by defining core activities and value drivers which are then supported by a collection of focused objectives, initiatives, Key Performance Questions (KPQs) and Key Performance Indicators (KPIs). RQIA recognizes that this is the work that enables the delivery of the strategic elements described on the map. The map by itself provides a clear sense of direction. Let's consider two examples (one a core activity and the other a value driver) of moving from the strategic elements that appear on the map through each framework stage to the KPIs.

Improving Care

We begin with the core activity "improving care." The high-level description of "we encourage and promote improvements in the safety, quality and availability of services through the regulation and review of health and social care," is further defined as: "RQIA uses evidence-based best practices in its approaches to service inspection and review, with a strong focus on identifying and addressing areas where the quality, safety or availability of services can be enhanced for the benefit of patients or clients." This core activity is supported by three strategic objectives, each of which begins with "by the year 2012 we will have," thus articulating clear strategic deliverables. An objective example is "by the year 2012 we have evidenced that the result of our programme of inspections and reviews is having a demonstrable impact on service improvement." This objective is supported by the initiative "plan and carry out an impact analysis of the work of RQIA." Next we find the KPQ "What difference is our programme of inspections and reviews making to the quality, safety and availability of health and social care in Northern Ireland." Finally the KPI is the "annual analysis of the impact of regulation and review and activity on improvements in the safety, quality and availability of health and social care services."

We Will Actively Engage with Stakeholders

As a further example, consider the value driver: "we will actively engage with stakeholders." This is defined as "RQIA talks with and listens to its stakeholders in order to inform the direction and delivery of its work and seeks opportunities to work in partnership." This is supported by two strategic objectives, as one example "by 2012 we will have developed effective communication methods to meet the complex and varied needs of the Northern Ireland public," while initiatives to deliver to this objective include a commitment to "develop and implement a new communications strategy." KPQs include "how is our practice changing in relation to internal and external communication activity," and a KPIs example is "six-monthly progress report in the implementation of the communications strategy." We will now consider the objectives/initiatives, KPQs and KPIs that support the Strategy map in more detail.

Strategic Initiatives

"Once we had the map in place we developed a template through which we could identify strategic objectives to support the high-level goals," explains Atkinson. "Then we identified the initiatives that will deliver those objectives. These initiatives, he explains, are identified or renewed each year as part of the annual business planning process. "This is where we determine the initiatives and action plans we need to put in place in a particular year to deliver to the longer-term strategic elements described on the map." In short, initiatives play a crucial role in the delivery of annual milestones for the 2012 strategic plan. This also helps ensure that the annual and strategic planning processes are closely integrated, which is not the case in many organizations.

Key Performance Questions

KPQs are an API innovation that focus on and highlight what the organisation needs to know in terms of delivering against existing strategic goals. KPQs enable a full and focused discussion on how well the organisation is delivering to these goals and serves as an important bridge between these goals and the KPIs. Indeed KPQs are used to provide a performance context to KPIs and to more effectively prioritise the indicators chosen. Atkinson explains the benefits that RQIA has gained from the use of KPQs. "Although a new concept for us, KPQs have proven critical in creating a bridge between strategic goals and our thinking in terms of performance measurement," he says. "They helped us to better clarify the purpose and role of KPIs.

Key Performance Questions

With KPQs as the starting point, RQIA's KPIs were developed as a sub-project within the strategy development exercise. "We set up a project team to develop KPIs which was led by the head of information and a senior quality reviewer," says Atkinson. Also included were senior managers who would become KPI owners as well as representatives from the information department - responsible for data collection." Metric selection was via a tailored version of an API template for KPI creation. Figure 2 shows this KPI template. Interestingly Atkinson states that the development of the KPIs was probably the most challenging aspect of the whole strategy development project. "Being a young organization RQIA has not as yet developed a culture of, or capabilities in, using performance metrics," he says. "Therefore we found that the KPIs developed were oftentimes more operational than strategic in nature and they didn't necessarily answer the KPQs as fully as they should."

To address the challenges, a project is presently under way to revisit the KPIs with a view of making them more strategic in nature. "We need to develop indicators that enable the board and executive team to learn, to better inform decision-making and to help steer and improve future performance", says Atkinson. API will be further assisting RQIA in developing more strategic KPIs and, importantly, helping to inculcate the appropriate mindset for working with and getting the best results from metrics.

Performance Reviews

RQIA is also presently looking at how to use the map more effectively for reporting purposes within the organization. That said, there have already been significant improvements to reporting as a result of the strategy development process. "Prior to the formulation of the map we would have had two reports: one being an update on the business plan and the other an activity report," explains Atkinson. "But now we've moved to one integrated progress report based on the Strategy Map that is presented to the board on a quarterly basis." This, he continues, has significantly streamlined and vastly improved the quality of reporting in monitoring how well RQIA is progressing toward its strategic goals."

Benefits So Far of Using the Strategy Map

With this case study prepared just under a year after going live with its 2009-2012 strategy, RQIA is already reporting significant benefits from using a Strategy Map as its core tool for managing and monitoring the implementation of strategy. The Chairman, Dr. Carson commented that "the key benefit of the map is that is it a visual representation of what we need to do to deliver to our strategy and realize the benefits that flow from that." The Chief Executive, Glenn Houston agreed with this view and added that "it provides a clear strategic roadmap and enables a shared organization-wide view of the strategic direction." This has led to the annual business planning process and discussions around the most effective deployment of resources, being much easier and more streamlined as they are anchored to achievements as described on the map. Communication is another clear benefit of the map creation, according to Atkinson. "Soon after the map was finalized, managers from various departments were asking for a PowerPoint version as they found it an easy and powerful way to communicate RQIA's strategy and role of the organization to staff and stakeholders," he says. "The strength of a Strategy Map for communication purposes should not be underestimated."

Future Developments

Although there is still work to be done in relation to the wider strategic performance management framework, especially with regard to KPIs, Atkinson believes that the Strategy Map itself will not change over the 3-5 year duration of the strategy, unless there are fundamental changes to the role or functions of the organisation. "What might change on a year on year basis, however, are the objectives and initiatives created to deliver to the elements on the map." This is appropriate as it is at this level that the work to deliver to the elements on the map takes place.

Critical Success Factors

In conclusion, Atkinson points to several critical factors that he believes to be vital for succeeding with a Strategy Map and supporting strategic performance management framework. Firstly he stresses the importance of ensuring buy-in at all organizational levels and across stakeholder groups. "For the strategy map to be deployed successfully it's critical that it is widely accepted," he stresses. "We ensured buy-in by being fully committed to stakeholder involvement and communication throughout the process. We did that via staff meetings, workshops, presentations and consultations and through any other vehicle that became available." Secondly, Atkinson also stresses the importance of external facilitation. "This was very important as it provided early momentum and expertise and provided a solid foundation for future work," he comments. "An important point to make is that the methodology provided by API was powerful. People really bought into it and found it useful and, crucially, soon realized that it worked. " Finally, and above all others, Atkinson highlights the critical importance of leadership and ownership from the top. "This is not surprising, but is absolutely critical," he says. "I led the project as Director of Corporate Services but it was championed by the Chief Executive, other members of the Executive Team and by the whole board." He continues that the project was characterized by joint and collaborative working at the most senior levels within the organization. "Without this commitment, dedication and ongoing support from the very top, I doubt whether the exercise would have been as successful as it has been," he says.

Bernard Marr is a globally regognized big data and analytics expert. He is a best-selling business author, keynote speaker and consultant in strategy, performance management, analytics, KPIs and big data. He helps companies to better manage, measure, report and analyse performance.
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