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Strategic Imagination

¹ Department of Radiology, Indiana University School of Medicine, 702 N. Barnhill Dr., Rm. 1053, Indianapolis, IN 46202.

Received February 4, 2000; accepted after revision March 20, 2000.

 
Address correspondence to R. B. Gunderman.

Introduction

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 

"Cheshire Puss,...would you tell me, please, which way I ought to go from here?"

"That depends a good deal on where you want to get to," said the Cat.

"I don't much care where—" said Alice.

"Then it doesn't much matter which way you go," said the Cat.

"—so long as I get somewhere," Alice added as an explanation.

"Oh, you're sure to do that," said the Cat. [1]

A transatlantic jet airliner entered a large storm system where it was buffeted about by strong winds. During the most intense turbulence, the passengers were startled to hear a loud crash in the cockpit. Several minutes later, the captain's voice was heard over the plane's public address system:

Ladies and gentlemen, we have sustained some damage as a result of the storm. Fortunately, I have good news as well as bad news. The bad news is that our plane's navigational system is ruined, and we don't know where we are going. The good news is that we have a strong tailwind, and we're making record time.

Unfortunately, this story rings true for many radiology leaders who find themselves tossed about in a sea of turbulent health care change. Many have found themselves struggling so furiously just to keep their organizations' heads above water that they have little energy left to think about where the currents are carrying them. Moreover, merely treading water is no way to navigate; you get nowhere, you soon grow exhausted, and you end up drowning anyway. Regardless of how treacherous the immediate health care situation, radiology organizations cannot afford to overlook two key considerations: where they want to go, and how they are going to get there.

The future of radiology hinges on the quality of its leaders' strategic planning. As the challenges confronting radiology in the health care marketplace mount, radiology's commitment to strategic planning must grow apace. More than ever, meeting that commitment entails the cultivation of creativity—a creativity not typically found in the frameworks of business and science. The language of business is great for formulating and evaluating action plans once a strategic plan has been produced, but a business model dominated by accountancy limits vision [2]. A narrow focus on the bottom line impedes key strategic activities such as self-education and creative scenario formulation. The situation is similar with scientists who may find it difficult to tolerate the imprecision and complexity that necessarily characterize a strategic outlook.

To prepare their organizations to meet the challenges that lie ahead, radiology leaders need to cultivate a strategic outlook. They need to critically examine their own assumptions and biases. They need to ask not only "what is" but also "what if." And they need to develop and sustain a dynamic interchange between radiology and the broader world, expanding their notion of relevance to encompass information that is not merely accurate but thought-provoking.

The benefits of strategic planning are manifold [3]. Strategic planning enables an organization to develop a well-grounded identity, fostering consistency in decision-making and the development of clearly specified goals. It encourages leaders to study the present situation and to plan for the future, helping them to recognize when change is vital. It invites them to innovate. It requires leaders to communicate, both among themselves and with other members of their organization. It makes the organization a more coherent and cohesive whole. Finally, it may improve financial performance. Implicit in each of these benefits of strategic planning is an important attitude: the plan itself, which soon becomes obsolete, is less important than the process of sharing perspectives and developing new ideas.

What are the elements of a strategic plan? Arranged hierarchically, and moving from top to bottom, they include mission, vision, strategy, goals, objectives, and actions [4].

Mission

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
The organization's mission is its purpose for being. One of the most damning criticisms one could level at any organization would be that it has no mission. Without a mission, the organization does not know what it is trying to do; like an aircraft without a destination, its outcome is likely to be unsatisfactory. No less crippling to an organization's performance than lacking a mission is failing to ensure that its members know the mission. If people do not understand how their job fits into the overall goals of an organization, then their ability to contribute to the achievement of those goals is compromised. The members of an organization must know its mission, see it clearly, and share an enthusiasm for pursuing it. If they don't believe that the organization would be worse off without them and that the world would be worse off without the organization, then it is time to reexamine the mission.

Vision

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
The vision of an organization is a mental picture of what it is trying to become in the future. The mission provides a frame of reference for the vision, but a mission alone is not enough because it does not specify how the organization's purposes are going to be achieved. If the mission tells why erecting a new building is necessary, then the vision describes what that building will actually look like. It gives members a sense of what they are moving toward; therefore, it helps to create a sense of forward motion. It is important periodically to check the vision against the mission, to ensure that the future the organization is working toward accurately reflects its reason for being. For example, is the primary mission of a radiology department to aid the sick or to secure comfortable lifestyles for its faculty, and how does the ranking of these two priorities translate into a vision of the department's future?

Strategy

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
The strategy provides a plan for achieving the vision. It is not enough to know what the organization is trying to become. One must also understand how it is going to do so. There are many possible routes by which to reach a particular destination, and strategy formulation considers factors such as effectiveness and efficiency in selecting among them. Effectiveness is the probability that the destination will actually be reached, and efficiency is the quantity of resources that must be expended to do so. A highly efficient strategy is one that achieves the vision with a minimum of wasted resources. The fact that efficiency appears only at the level of strategy, subordinate to mission and vision, highlights the secondary role that considerations of efficiency play in the strategic planning process. Efficiency calculations can be used to rank alternative routes to a destination; however, they cannot specify what the destination ought to be.

Goals

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
Goals are specific targets for achieving the organization's vision. A common strategy for formulating goals is to periodically construct top 10 lists of key goals that must be pursued if the organization is to achieve its vision. Generally, such goals should be specified at least every few years and more often in an environment of rapid change. Goals are not written in stone and will often change with circumstances, but they provide a vital framework for strategic operations.

Objectives

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
Objectives are shorter term targets that must be reached to achieve goals. These must be clearly feasible and include measurable performance parameters. For example, an academic radiology department might establish as an objective that its extramural grant support should increase by a certain percentage in the next year.

Actions

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
Actions are specific tasks that must be accomplished to achieve objectives. These are assigned to particular individuals, have clearly defined time frames, and specify accountability for their completion. By using actions to build short-term wins into the strategic planning processes, leaders can help to ensure that morale and momentum toward longer term strategic goals are maintained.

Values

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
Permeating all levels of the strategic plan are the organization's values. These values powerfully influence the performance of the organization because they define its basic way of doing business: how targets are formulated, how individuals are rewarded, how disagreements are handled, and so on. What ideals of character and conduct does the leadership of the organization embody? This ethical tone has a profound effect on all other aspects of the organization's performance. For example, if the leaders of an organization are seen as out of touch, uncaring, or hypocritical, the organization is unlikely to succeed no matter how well constructed its strategic plan may be [5].

Strategy

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
The word "strategy" is drawn from Greek roots and means the leading of an army. In military parlance, strategy is distinguished from tactics, the former referring to largescale military operations in which a force is maneuvered into an advantageous position before engagement with the enemy. Most battles are decided before the first shot is ever fired on the basis of tactical skill, not on strategic imagination.

Every organization's resources are limited, and the goal of strategic leadership is to plan the allocation of resources in a way that produces the maximum medium- and longterm payoffs. Many of us spend too much time thinking tactically, taxing our ingenuity to solve problems on an ad hoc basis. By dint of years of experience in the trenches, we become quite good at bandaging wounds, but too often we fail to step back and examine the system that repeatedly produces the injuries in the first place.

A strategic approach means adopting a more global perspective and thinking creatively about how to improve the system, be it a process or an organization. It means asking radical questions about why the system is the way it is and whether it really ought to remain that way.

Physicians are by nature a notoriously conservative lot. Since our first days in medical school, the Hippocratic maxim, "First do no harm," has been driven home to us. Driven to excel in school, we become adept at recalling what the textbooks and teachers told us to learn. In radiology residency, we generally continue the pattern, memorizing patterns, facts, and procedures, with little attention to creativity. Ask most radiology residents what they want to learn, and they will show you a textbook. The implicit messages in most residency training are, "Know everything," and "Don't make a mistake." The curriculum fosters conformity, not creativity, which is not what radiology organizations confronting today's challenges need.

The future of radiology does not depend on developing leaders who are so careful that they never make mistakes. Quite the opposite—it depends on developing leaders with the courage to take risks, the judgment to know which risks are worth taking, and the ability to learn from their mistakes [6]. Show me a department chairperson who has never made a mistake, and I'll show you a department in desperate need of new leadership. Events in Silicon Valley over the past decade or two powerfully illustrate that our culture rewards innovation, not conservatism. Internet-based companies that did not even exist until several years ago are now gobbling up large firms that have been around for decades. Those who adopt a defensive posture and attempt to insulate themselves from change become mere stepping stones for innovators who are helping to blaze new trails.

The greatest adversaries of innovation are complacency and fear. Good enough is the enemy of better, and radiologists who are satisfied with the status quo are unlikely to effect significant improvements [7]. Every radiologist has colleagues whose posture toward the future can best be described as defensive. Their attitude is like that of Lord Salisbury, who argued that whatever happens will be for the worse, so it is best that as little should happen as possible. They regard strategic planning with suspicion and disdain, attempting to disarm good-faith innovators with cynicism and even ridicule. So long as key constituents within a department regard the unknown as more threatening than the status quo, meaningful innovation is impossible. When those constituents are at or near the center of a department's orbit, the degree of inertia can be insurmountable. Innovators find themselves pushed out to the periphery of the organization, where their voices are barely audible.

Imagination

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
One of the key traits of an imaginative leader is openness. True effectiveness in leadership is characterized less by the ability to get people to do what you want them to do than by the ability to hear what they have to say and put it to use. As we move into an increasingly knowledge-based economy, with its emphasis on freedom and creativity, the open exchange of information and ideas represents an increasingly vital ingredient of success. The totalitarian state, as embodied by the former Soviet block, illustrates the very antithesis of a model for successful leadership. In the future, outstanding leaders will be defined not by how much power they wield but by how much they know, and how much they know will depend on how well they listen. Knowledge is the number one commodity, and it is the only good that actually multiplies when shared [8].

To be successful, departments need to be structured in ways that promote and encourage the free exchange of information and perspectives, with emphasis on the latter. Most leaders are overburdened with information, but undersupplied with perspectives—by which I mean new and fruitful ways of looking at their organization and the choices it faces. Leaders should strive to be the number one consumers and disseminators of perspectives in their organizations, while building a culture that encourages everyone at every level to learn and share what they know. Effective strategic planning requires inclusiveness, taking advantage of as many perspectives as possible. In part, there is political benefit in listening to others, especially those in powerful positions. More important, this sharing of learning and perspectives constitutes one of the most significant benefits of the strategic planning exercise, and frequently enriches the organization more than the plan itself.

Especially valuable to the creative leader are associates who help them to look at problems in new ways. Such a person is the direct opposite of a yes-man. Leaders need associates who help them to learn continuously, especially by repeatedly challenging them to reexamine their assumptions and biases.

An insulated leader is an ineffective leader. Leaders need constant exposure to new perspectives, including people and ideas outside of their field. The solutions to the important problems facing us rarely lie within the boundaries of the discipline that created them. Instead of adding still another radiology journal to their weekly reading list, imaginative leaders will spend an hour a week with a perspective-rich newspaper such as The Economist. They will read and attend conferences in disciplines related to but outside their field. They may even enroll in courses in interdisciplinary subjects whose relevance more conventional thinkers would question. The muscle of creativity is strengthened by the stimulation that such ongoing interdisciplinary experience provides. When it isn't challenged, that muscle grows weak and flabby, and the organization whose future depends on it suffers as a result.

Creativity requires a questioning attitude [9]. Leaders who think they have figured out how the world works may thrive for a time, but important aspects of the environment are changing at an ever-accelerating pace. Only through continuous investigation can the leader ensure that organizational strategy is appropriately attuned to the true state of affairs. Every important decision involves uncertainty, but intelligent questioning can reduce that uncertainty to acceptable levels by producing a clearer perception of what the world really looks like.

A sober assessment would indicate that we never possess perfect information. Every strategic decision is a wager—a hypothesis predicated on uncertainty. But imaginative leaders know that risk and reward are tightly correlated. As a consequence, they view uncertainty not as a handicap, leading to a paralysis of judgment, but as an opportunity for innovation, with huge potential rewards for the organization. If there were no uncertainty, success would be uniform among all organizations. But because uncertainty exists, leaders are able to use informational advantages to create scenarios of success. Examples of such scenarios would include, "What if the hospitals in my area seek to consolidate their radiology services?" and "What if the National Institutes of Health doubles funding of imaging research over the next 3 years?" The imaginative leader then considers how to position the organization to capitalize on such opportunities.

Assumptions about how the health care marketplace will evolve powerfully influence choices about how to position the organization [10]. For example, if purchasers of imaging services are expected to reward providers on the basis of cost reductions, then seeking to establish overall cost leadership would constitute a reasonable strategy. On the other hand, if market segmentation and the development of new services are seen as the trends of the future, then focusing on service differentiation may be the priority. For example, a department might choose to concentrate its resources on joint ventures with groups of other physicians to develop comprehensive short-stay and ambulatory health centers, instead of augmenting existing inpatient-centered imaging facilities. The goal should be not merely to develop a list of assumptions about where things are headed, but to question and continually refine those assumptions to get a clear picture of what is really happening. The organizations most likely to succeed are the ones whose vision extends beyond the box of conventional assumptions and who effectively integrate that vision into their strategic operations.

Socrates famously declared that the unexamined life is not worth living. Certainly the success of radiology organizations that do not engage in frequent self-examination is likely to prove short-lived. Such self-examination means above all a willingness to acknowledge and address deficiencies. The inability of physicians to face up to their mistakes means that underachieving programs may languish for years from sheer neglect, and their potential for dramatic improvement will remain untapped.

Everything an organization does needs to be subjected to close scrutiny, to determine whether current results are in line with potential achievement. Mistakes are not the harbingers of failure but the laboratory of success. To a frequently unrecognized degree, outstanding leaders succeed by creating a culture in which mistakes are not only tolerated but also cultivated. Genuine innovation is predicated on a willingness to take risks. If people aren't making mistakes from time to time, they aren't learning. And if they aren't learning from small mistakes, larger and more catastrophic failures become inevitable.

A culture that fosters strategic imagination is one whose members are encouraged to cast a critical eye on one another's assumptions and assertions, with a view to mutual education. If the members of an organization are so insecure that they cannot bear to have their perspectives questioned, then the leaders of that organization haven't been doing their job. What should be a vibrant culture of mutual learning has become a brittle regime of isolation and mistrust. Such a culture is antithetical to strategic imagination and to the opportunities for success it breeds.

Strategic Imagination

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 
Radiology is a supremely image-based specialty. Nearly all of its diagnostic and therapeutic capabilities are grounded in the production and interpretation of images. If radiology organizations are to thrive in the future, they need to expand this sphere of imaging expertise beyond the clinical care of patients to encompass the strategic imagination of organizations. They must examine and reexamine what they are doing in light of who they are and where they ought to be going. The strategically imaginative leader is one who can survey past trends and current circumstances in a creative way that enables the organization's core values to find new and richer expression in the future.

References

Top Introduction Mission Vision Strategy Goals Objectives Actions Values Strategy Imagination Strategic Imagination References

 

1. Carroll L. Alice's adventures in wonderland. New York: Delacorte, 1978:57
2. Eisenberg L. Marketplace medicine: Rx for disaster. Academe 1999;6:26 -30
3. Duncan WJ, Ginter PM, Swayne LE. Strategic management of healthcare organizations. Boston: PWS-Kent, 1995
4. Zuckerman AM. Healthcare strategic planning: approaches for the 21st century. Chicago: Health Administration Press, 1998
5. Gunderman RB. Images of the imager: the essential role of ethics in the future of radiology. Acad Rad 1999;4:148 -155
6. Agyris C. Teaching smart people how to learn. In: Business classics: fifteen key concepts for managerial success. Boston: Harvard Business School, 1998: 101-109
7. Kotter J. Leading change: why transformation efforts fail. In: Business classics: fifteen key concepts for managerial success. Boston: Harvard Business School, 1998: 101-109
8. Schwartz P. The art of the long view: planning for the future in an uncertain world. New York: Doubleday, 1991
9. DeBono E. Serious creativity. New York: Harper Collins, 1992
10. Porter ME. Competitive strategy. New York: Free Press, 1985

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