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Appendix L. Sample Strategic Sustainability Plan

Community quality collaboratives are community-based organizations of multiple stakeholders, including health care providers, purchasers (employers, employer coalitions, Medicaid and others), health plans, and consumer advocacy organizations, that are working together to transform health care at the local level. The Agency for Healthcare Research and Quality offers these organizations many tools to assist in their efforts.

Contents

Executive Summary
Introduction
  About This Plan
  Overview of the Organization
  What is "Sustainability"?
  Plan Development Process
Strategic Plan
  Sustainability Criteria
  Part I: Insights from the Environmental Scan
  Part II: Program Priorities
  Part III: Approved Strategies
  Part IV: Related Initiatives
  Part V: Financing
Turning Plans into Action
  Roles and Responsibilities
  Semi-Annual Review Cycle
Appendixes
  Appendix L-1: Recommendations for Quality Corporation Board Discussion, November 19, 2008
  Appendix L-2: Program Summary - Sustainability Planning Support Material for Setting Priorities, November 14, 2008
  Appendix L-3: Selected Slides from the Oregon Health Care Quality Corporation Board Discussion, September 17, 2008

Executive Summary

This document is a blueprint for how the Oregon Health Care Quality Corporation, a multi-stakeholder collaborative, will leverage its initial success and unique capabilities to build a sustainable business model that will deliver tangible value to the Oregon market.

This plan reflects the following core principles:

  • The unique value of the Quality Corporation is the power of multi-stakeholder collaboration.
  • The value of the Quality Corporation is grounded in its core services: aggregating health care performance data and publicly reporting.
  • In order to grow and be sustainable, the Quality Corporation must deliver tangible value to those who will support the organization.
  • The Board noted the particular importance of delivering on the core services and on existing commitments to current supporters, which will demonstrate the value of the Quality Corporation and its ability to execute.
  • The stakeholders who actively support the Quality Corporation place high value on these foundation services and on services that logically expand from this base.

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Introduction

About This Plan

The primary users of the plan are the Board members, stakeholders, and staff who are working together to improve health care for all Oregonians.

Contributors

The Board of Directors designated a Market Scan and Sustainability Committee (referenced throughout this document as the “Committee”) to build this plan, with the help of an outside consultant, Lisette Lejnieks.

The consultant was funded substantially by the Agency for Healthcare Research and Quality (AHRQ), as part of the Learning Network for Community Quality Collaboratives (Community Quality Collaboratives) created by then-Secretary of the U.S. Department Health and Human Services Mike Leavitt.

In addition, the Puget Sound Health Alliance and Social Entrepreneurs Inc. of Reno, NV, shared templates and examples that were very useful in shaping the format and content of this document.

Overview of the Organization

The Oregon Health Care Quality Corporation is a broad—based collaborative recognized as a charitable, non-profit 501(c)(3).

The Quality Corporation provides both a forum for sharing information and best practices and a mechanism to identify strategic projects for improving health care through community based activities. The collaborative seeks to strengthen, not duplicate, the work of other organizations engaged in quality improvement in the Oregon healthcare marketplace.

The Board is drawn from health plans, physician groups, hospitals, public sector health care representatives, purchasers, health care providers, consumers, and others with a commitment to improving the quality of health care in Oregon. The Board of Directors is continuously rebalanced so that all stakeholder groups are represented. Over three hundred individuals who care about health care quality have contributed to the Quality Corporation's projects.

Vision: Oregonians are healthier because:

  • The health system is accountable for providing high quality and high value.
  • Providers are continually improving the quality of care they provide.
  • Consumers are full partners in managing their own health.
  • Accurate information is readily available at the personal, practice, and community level.

Strategies:

  • Make quality of care information available
  • Help health care providers continually improve their care quality
  • Help patients and the public understand their role in recognizing and contributing to high-quality care
Accomplishments to Date

The Quality Corporation was created in 2000 and secured its first funding in 2003. The first staff members (part-time) were hired in 2004.

In this short time, the organization has contributed significantly to improving health care in the State of Oregon. Highlights include:

  • Completed a chronic disease pilot demonstrating how to surmount the political, legal, and practical challenges to cooperatively deliver 12 health plans' data to health care providers for improved care
  • Initiated full implementation of the data pilot. Secured funding and legal agreements from the state's largest insurers; developed the measurement plan; contracted with a data aggregation vendor; acquired data; and solicited providers' input for developing useful products.
  • Developed and disseminated consumer engagement strategy and materials
  • Completed health information exchange (HIE) planning, including privacy and security framework, “Where to Start for HIE” guidelines, business case for statewide implementation, and HIE implementation plan
  • Became a national leader in regional multi-stakeholder improvement
  • Designated as a Robert Wood Johnson Foundation Aligning Forces for Quality site
  • Selected by the U.S. Department of Health and Human Services to be a Community Quality Collaborative

What Is “Sustainability”?

Sustainability, in its simplest terms, is the ability to sustain or continue over time. For the Quality Corporation, the pursuit of sustainability means building, maintaining, and refining an infrastructure that supports and advances the mission of the organization, as well as the organization itself, as market and stakeholder expectations change.

Sustainability is not limited to funding or succession plans, but encompasses organizational structure, financial planning, the community of participants, and their approach to collaboration. Therefore, this Strategic Sustainability Plan is designed to address all of the components that must work together to sustain the mission and the organization.

Leading Practices for Sustainable Collaboratives

The Community Quality Collaborative Sustainability Program, funded by AHRQ has identified seven Leading Practices among successful multi-stakeholder collaboratives in the health care arena.

The seven Leading Practices are:

  1. Responding to Compelling Market Circumstances
  2. Maintaining Effective Leadership
  3. Achieving Balance Among Stakeholders
  4. Delivering Tangible Value
  5. Communicating Proactively
  6. Establishing a Transparent Management Style
  7. Employing Rigorous Prioritization

Following an evaluation of the Quality Corporation's current state and prior activities, this Plan was developed with a particular focus on the following challenges:

  • Responding to compelling market circumstances (Leading Practice #1)
  • Delivering tangible value (Leading Practice #4)
  • Employing Rigorous Prioritization (Leading Practice #7)

This plan also incorporates and/or references the work of other Committees and Projects within the Quality Corporation. Through a separate parallel process, the Leadership and Governance Committee and the Executive Committee addressed three other leading practices:

  • Maintaining Effective Leadership (#2)
  • Achieving Balance Among Stakeholders (#3)
  • Establishing a Transparent Management Style (#6)

The process and results for this additional work are discussed in section IV and are included in the implementation plan.

The Quality Corporation staff also addressed leading practice #5—Communicating Proactively—by hiring a communications coordinator, initiating a newsletter, and enhancing communications with two key audiences: consumers and clinicians.

Plan Development Process

The recommendations reflected in this Plan were shaped in multiple meetings of the Market Scan and Sustainability Committee, referenced throughout this Plan as the “Committee”, and refined in three iterative Board meetings in July, September, and November 2008.

The recommendations reflected in this plan were unanimously approved at the November Board meeting. The document itself was approved at the January 21, 2009 Board meeting.

The chart below illustrates the strategic planning process, which was applied as follows:

  • The Vision had already been well defined, and was affirmed by the Board at the first planning session.
  • Therefore, the Committee focused on confirming the Universe of Potential Program Work and the intersection of Capabilities, Priorities, and Funding.
  • This Plan reflects those conclusions and defines the resulting Strategies, Execution Plan, and Monitoring approach.

This wiring diagram shows the planning process that begins with a vision and results in a project being executed. The wiring diagram begins with Vision at the top with a downward pointing arrow pointing to the words Universe of Potential Program Work. Beneath these words is is a downward pointing arrow leading to three arrows forming a clockwise circle with the words Capabilities, Priorities, and Funding between each arrow. Beneath this graphic is a downward pointing arrow leading to the word Strategies. Beneath Strategies are two downward pointing arrows leading to the words Execution and Monitoring, which are linked by a horizontal pointing arrow.

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Strategic Plan


Sustainability Criteria

The Board affirmed the following criteria for the planning process and the resulting Plan:

  • Advances the mission: Leads to real solutions for improving health care quality through better information and increased communitywide collaboration
  • Acknowledges and responds to compelling circumstances
  • Leverages the unique value of the Quality Corporation
  • Delivers tangible value to stakeholders within a timeframe that will keep their attention
  • Meets the expectations of current funders
  • Attracts the attention of potential new funders

Part I: Insights from the Environmental Scan

To find the right balance between capabilities, stakeholder priorities, and funding, input was gathered from three sources: successful collaboratives in other markets, regional market leaders, and Quality Corporation stakeholders.

Comparison to Health Care Collaboratives

As a benchmarking exercise, the Board reviewed and discussed business models of similar collaborative organizations in other regions. In particular, the Board discussed the sources of funding and the programs (or uses of funding) of successful collaboratives that focus on health care quality.

This comparative information is included in Appendix C: Selected Slides from the Oregon Health Care Quality Corporation: Board Discussion: September 17, 2008.

This discussion led to the following key conclusions:

  • The Quality Corporation has been very successful in growing its annual funding base from $60,000 to $1.2 million in about 4 years.
  • The Quality Corporation's current funding model is less diversified than the models of comparison organizations. Those organizations receive funding from more diverse sources.
  • In particular, other health care collaboratives receive more funding support from Government sources and purchasers than the Quality Corporation currently receives.
  • Diversification is important to the Quality Corporation as protection from loss of funding and in shaping the priorities for using the funds.
  • At the same time, diversifying funding in Oregon's market place is particularly challenging because of the predominance of small employers, small-provider clinics, and low per capita government base.
Program Mapping Scan: Where Is the “Energy”?

The planning process included one-on-one interviews of seven leaders in the Oregon health care market to gather current information about what other groups are doing, stakeholder and funder interests, and potential program and funding opportunities. A summary matrix was provided to the Executive Director.

Following are the major conclusions from the Scan and the subsequent discussions with the Committee and the Board:

  • Quality Corporation has a clear niche. Respondents consistently recognized and respected the multi-stakeholder approach. They were not aware of “competitors” having that qualification.
  • Stakeholders advised both against thinking “too small” as well as cautioned against taking on too much.
  • There was a frequent perception that “nobody” is leading or innovating across stakeholder groups in key areas. While there are groups innovating, those innovations may be viewed as internally focused.
  • Stakeholders expressed increasing interest in the subjects of access & affordability, out of necessity. This was consistent with findings in other markets as well.
  • The Oregon Business Council was launching a Health Leadership Taskforce: convening health care industry leaders to hold cost increases to the Consumer Price Index (CPI).
  • Oregon has good ideas, but collaborative execution has been a challenge.

In addition, the Scan yielded the following key points about the pending state health reform recommendations:

  • All respondents noted considerable energy around the reform recommendations and expected key components to move forward.
  • Key respondents expected nonprofits and public-private partnerships to have a significant role in executing those recommendations.
  • Respondents also expected the State of Oregon to take a “partner/buy” vs. “design/build” approach.
  • There were differing opinions about the Quality Institute: whether the recommendations were likely to go forward, and which, if any, existing organization would be best suited to oversee some or all of the activities.
  • Several respondents suggested additional promotion of the Quality Corporation to position for future opportunities.

For more information from the Program Mapping Scan, including key points about specific programs, see Appendix C: Selected Slides from the Oregon Health Care Quality Corporation: Board Discussion: September 17, 2008.

Stakeholder Priority Surveys

The planning process included multiple surveys of key stakeholders, including Board members and selected others, to provide a comprehensive picture of expectations and priorities from various perspectives.

The survey feedback was used to affirm the prioritization of programs and relative allocation of resources. The charts summarizing the survey results are included in Appendix C. Selected Slides from the Oregon Health Care Quality Corporation: Board Discussion: September 17, 2008.

For more information about each current program, see Appendix B: Program Summary: Sustainability Planning Support Material for Setting Priorities, November 14, 2008.

Part II: Program Priorities

Quality Corporation Niche

The specialized niche of the Quality Corporation is its multi-stakeholder collaborative model, for which there is no direct competitor in the state of Oregon. Several other organizations also bring together competitors within health care market sectors. However, the Quality Corporation is the only entity bringing together purchasers and consumers with the health plans, clinicians, delivery systems and government to select, design, develop, finance, and implement specific programs.

The core value and leading product of this model is the consolidated approach to measurement and public reporting of ambulatory care quality. Strategic discussions centered on how to leverage that niche and core value into a sustainable business model that builds from the core. For example, a critical discussion occurred to determine whether the true value was in the aggregation of data or in what is done with the data.

The priority charts that follow provide more details to support the Board's strategic direction:

  • Focus on delivering on existing commitments (core measurement and public reporting activities),
  • Expand the types of data that are measured and reported, and
  • Leverage the data to stimulate appropriate actions.
Program Priorities

The following charts illustrate the Board's decisions for allocation of staff and financial resources. The work of contractors has been roughly translated to FTEs in order to have a single metric for allocating effort. Each block represents approximately 1/10 of an FTE. The substantial in-kind contributions from partner organizations are not included in these charts.

The tracks identified in the chart were created to consolidate the top-ranked program activities into related efforts. These tracks correlate with the historical sources of funding and the sources of program energy and framing. A full explanation of each program activity is contained in Appendix B: Program Summary.

  • Track 1 represents the measurement and reporting activities identified and funded by Oregon's stakeholders since its inception. Foundations are also funding some of the Track 1 work.
  • Track 2 consolidates the additional commitments that the Quality Corporation has made for improving the quality data and for supporting its use by various stakeholders to improve care. This work is largely funded by foundations.
  • Track 3 represents primarily the Executive Director's time advocating for the Quality Corporation's issues and contributions in the larger community.
  • Track 4 represents the top priorities for new work, which is currently unfunded.

The priorities column refers to the rankings of program activities that led to these priorities. “C” refers to current work and “F” refers to future work. Items indicated “xx” were not ranked, but emerged through discussion and revision.

Table A—Program Priorities: Current State

The following chart illustrates the current distribution of work effort across programs, as of November 2008.

This chart outlines the work efforts across the groups programs. It lists the different activities the organization attempted, such as aggregating data and publishing quality data. It includes codes to rank the priority of each activitiy and also how many full time equivalents (personnel hours) were used to accomplish the activities.

The Board members affirmed that reviewing the current commitments was very informative and useful to level-set members' understanding of how resources are being allocated. In particular, the pursuit of additional grant funding had added commitments that were not clear to all Board members. This process also increased the Board's awareness of the magnitude of the Quality Corporation staff's engagement in the larger policy arena. This led to a beneficial discussion of the relationship and boundaries between policy engagement and sustainability.

Table B—Program Expansion: Immediate Horizon (2009)

The following chart illustrates the desired migration from the current activities to incorporate additional work, as directed by the Board, which is focused on logical extensions of the actual work in progress. This distribution assumes that the available resources will remain constant in 2009, and that existing resources will be used to initiate the new work. Some of the work in 2009 involves securing additional resources for the expanded work beyond 2009.

This chart outlines the work efforts across the groups programs. It lists the different activities the organization attempted, such as aggregating data and publishing quality data. It includes codes to rank the priority of each activitiy and also how many full time equivalents (personnel hours) were used to accomplish the activities. Additionally, it shows how additional activities will be added and the number of full time equivalents that will perform the work.

Key Points About 2009 Priorities

Track 1: The Board determined that preparing to expand the measurement and reporting function to additional types of clinicians and additional types of data is appropriate, and in fact essential, to sustainability. In exploring the work of similar organizations in other communities, specialists and measures of efficiency are the logical next step to bringing value to the Quality Corporation's active stakeholders.

Track 2: The Board determined that the largely discretionary resources being provided by Foundations to support Track 2 are being appropriately allocated and should continue.

Track 3: The Board recommended that the Executive Committee provide additional support to the the Executive Director on development and sustainability issues. Furthermore, the Board directed that more resources be focused on the health policy sector, to ensure that the Quality Corporation's expertise is available and that the organization is well-positioned for potential opportunities.

Track 4 generated considerable Board discussion. Members had distinctly different ideas about what these items really mean, how closely they fit with the Quality Corporation's expertise, and whether the Quality Corporation's role is as catalyst for initiation or as the implementer of on-going programmatic efforts. Board members also differed on their enthusiasm for this expansion, with some finding it essential to enlisting physicians' support for the organization and others finding it a risk to core business. Board members did agree that if there is to be any expansion, the highest priority for that expansion is the intersection of a revised payment system to accompany support for specific quality improvement. The Board affirmed the need for a small amount of resources in 2009 to further clarify and develop this concept.

The Board also debated the addition of work to develop systems for collecting patient experience data. Stakeholders agree that the data are important, but that the cost of collection is quite large. This is a high priority for a key foundation funder, though the resources they provide are not commensurate with expectations. Though the Committee did not include this in their recommendations, the Board agreed to assign the Program Committee to explore options in 2009 and report back to the Board.

Table C—Future Vision (2010 and beyond)

The following chart illustrates the progression over time to incorporate additional work, as directed by the Board. This distribution recognizes that additional resources will be required for expansion and is dependent on the results of the 2009 efforts.

This chart outlines the work efforts across the groups programs. It lists the different activities the organization attempted, such as aggregating data and publishing quality data. It includes codes to rank the priority of each activitiy and also how many full time equivalents (personnel hours) were used to accomplish the activities. It shows the progression over time to incorporate additional work that the board of directors directs. It shows that additional resources will be needed to expand the project.

Part III: Approved Strategies

In support of the agreed upon progression of programs and priorities, the Board affirmed the following strategies. The strategies are organized around the program tracks. For a list of the programs or initiatives included in each track, see priority charts on pages 9 through 14.

The Board noted the particular importance of delivering on Tracks 1 and 2, which will demonstrate the value of the Quality Corporation and its ability to execute.
Track 1: Measurement and Reporting

As noted above, this track was affirmed to be at the core of the value delivered by the Quality Corporation.

Approved Strategies:

1.1 Define checkpoints to obtain objective feedback from stakeholders on the value created (to confirm that the effort is on target).
1.2 Evolve toward reporting on specialty care and efficiency/value.
1.3 Evaluate overlap in data aggregation activities with Health Fund Board recommendations.
1.4 Confirm what is needed to ensure funding by Health Plans will continue.
1.5 Identify opportunities to expand and diversify funding beyond 2010.

Track 2: Foundation Commitments

This track includes work already committed, based on Foundation Grants, although there is considerable flexibility to design programs that achieve the specified goals.

Approved Strategies:

2.1 Actively maintain relationship with the Robert Wood Johnson Foundation.
2.2 Scan other foundations for interest in funding specific work.
2.3 Track Oregon Health Fund Board recommendations for program/funding opportunities.
2.4 Further explore health plan interest.
2.5 Further explore purchaser interest.
2.6 Assign Patient/Provider Experience subject to Program Committee for further evaluation.

Track 3: Organizational Development

This track includes activities focused on sustainability and development of the Quality Corporation, such as strategic planning, developing relationships, and identifying and pursuing funding opportunities.

Approved Strategies:

3.1 Delegate ongoing oversight responsibility and active role in supporting Executive Director to Executive Committee
3.2 Identify opportunities to expand and diversify funding, specifically: 3.3 Compare benchmarks of funding by plans in other communities.
3.4 Define opportunities to expand plan funding in Oregon.
3.5 Compare benchmarks of funding by purchasers in other communities.
3.6 Define opportunities to expand purchaser funding in Oregon, particularly through the Oregon Business Council Leadership Committee.
3.7 Compare benchmarks of funding by providers in other communities.
3.8 Define opportunities to expand provider funding in Oregon, such as selling provider-clinic crosswalk lists.
Track 4: New Program Development

This track includes significant new program opportunities that were identified as high priorities by stakeholders and in Board discussions.

Approved Strategies:

4.1 Create working group to further explore aligning and enhancing quality improvement initiatives; learn from the Minnesota ICSI and other models, define options, and make recommendations to the Board.
4.2 Identify potential quality improvement “demonstration project” to progress toward a more robust quality improvement support model.
4.3 Rename “Provider Incentives” as “Payment Reform that supports the quality improvement initiatives” and assign to Executive Committee for further evaluation.
4.4 Explore reasonable cost opportunities to better coordinate, consolidate, and report efforts to measure patient experience of care.

Track 5: Watch List

This track recognizes that there are additional programs that are valued by Quality Corporation stakeholders that are not on the current plan due to various reasons such as resource constraints, lack of funding, and/or lack of clear direction.

The Executive Committee is charged with monitoring these subject areas for new developments, such as changes in the regional market, advancements in other markets or national efforts, new funding sources or opportunities, and shifts in stakeholder priorities.

Approved Strategies:

5.1 Formally revisit the Watch List at least every six months.

Part IV: Related Initiatives

This section highlights critical strategic work that has been or will be developed in conjunction with the sustainability planning process.

Governance (Balance Among Stakeholders)

The Board updated its bylaws, created policies and procedures for governance, instituted Board member terms, developed criteria for Board member selection, created a Board job description, and initiated a Board commitment process. This Committee then applied procedures for examining stakeholder representation and aggressively recruited new members to achieve better balance on the Board and on the Executive Committee for 2009. The organization also adopted a Conflict of Interest Policy, formally chartered Committees, and adopted a Milestones Dashboard to monitor projects.

While this is significant progress, the Board will need to continually revisit governance issues to assure that the Quality Corporation is staying in touch with the community direction, recruiting and listening to community leaders, and fulfilling its niche as the organization that balances consumer, purchaser, plan, provider, and government interests. With approximately one-third of the Board members new to their role in 2009, the Governance Committee also will need to address orientation and integration processes.

Internal Capacity Building

Strong internal systems, including financial management, leadership and facilitation skills, staff capabilities, and operational processes, are essential to be fully effective as a collaborative.

The scope of this planning process did not include assessing capacity strengths or building plans to address weaknesses. It was assumed that the Quality Corporation had sufficient internal systems and capacity to meet the current plan and the skills needed to build capacity for the future plans. In addition, evaluation work had recently been completed with the Robert Wood Johnson Foundation.

As the Quality Corporation works through the current Plan and delivers on its defined priorities, there may be a need to revisit and define strategies for increasing capacity.

Part V: Financing

This plan is based on the following view of current sources of funds and uses of funds. Funding is adequate to support the priority programs through 2009. The plan itself identifies the need for expansion of funds to support priorities in 2010 and beyond. For more information about the approved strategies to achieve this goal, see pages 15 and 16. “Measurement” and “Website & Data” relate to Track 1 in Tables A, B, and C. “Sustainability & Admin” relates to Track 3. All others relate to Track 2.

This pie chart shows current expeditures by programs. Hospital Partnerships on National QIs $1,000; Partnerships on Disparities $1,000, Health Policy $1,000, Sustainability and Admin $7000, Website and Data $80,000, Consumer Engagement $90,000, Other $100,000, Assist Clinics in Using Infro $110,000, Measurement $610,000.

This pie chart shows current employee time by program in staff full time equivalents. Hospital Parnership on National QU 0.1, Heath Policy 0.1, Partnership on Disparities 0.1, Measurement 1.4, Assist clinics in using info 0.6, other 0, consumer engagement 1, website and data 1.1, sustainability and admin 0.6.

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Turning Plans into Action

Roles and Responsibilities

As part of the sustainability discussions, the Board designated the Executive Committee to have ongoing responsibility for supporting the staff in delivering on the plan and monitoring progress. The Executive Committee will either manage, or appoint a committee to manage, development of new work (Track 4).

The following chart highlights roles and responsibilities specific to this Plan. These responsibilities should be integrated with all other defined responsibilities for each defined role.

Role

Responsibilities

Timeframe

Board of Directors

  • Approves Strategic Sustainability Plan, including mission, priorities, and strategies.
  • Monitors progress through regularly scheduled updates.
  • Revisits the plan to affirm or revise at least every six months.
  • Bi-monthly Board Meetings
  • Email updates as needed

Each Board Member

  • Actively supports the Plan with their time and expertise, as well as public support.
  • Notifies Executive Director and/or Board of new developments, based on his or her industry-leading perspective.

Ongoing activities

Executive Director

  • Executes on the approved plan.
  • Notifies Executive Committee of obstacles and gaps.
  • Ensures that Plan reviews and updates are conducted as agreed.

Ongoing daily activities

Executive Committee

  • Monitors progress.
  • Supports Executive Director in resolving issues and removing obstacles.
  • Bi-monthly
  • Email updates and conference calls as needed

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Semi-Annual Review Cycle

The Board agreed to formally revisit and evaluate the plan at least every six months. Similar to the planning process that created this Plan, future reviews will include:

  1. Staff updates on the current state, including funding and program status
  2. Staff, stakeholder, and/or market leader updates on new developments
  3. Executive Committee previews and preparation
  4. Full Board review and affirmation of mission, priorities, and strategies

The Priority/Resource Charts provide a framework for confirming priorities and assigning resources.

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Page last reviewed January 2009
Internet Citation: L. Sample Strategic Sustainability Plan: Appendix L: Sample Strategic Sustainability Plan. January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/value/suscqcollab/suscqcollappl.html

 

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