hypothetical health promotion plan

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By Les MacLeod, EdD, MPH, LFACHE

Making SMART Goals Smarter

Goal-setting

In this article…

Study the differences between goals and objectives and get some valuable insights on how to use SMART goals in a health care organization.

A critical role of leadership is goal setting.1 As our health care system continues to evolve, physician execu- tives will be called upon to play increasingly proactive roles in formulating appropriate goals for their respective health care organizations (HCOs).

With what looks like a major perspective shift from provider-driven volume to consumer-driven value,2-4 physician leaders will be entrusted with the responsibility of ensuring high standards of care throughout the extended process of resource realignment.

How well they are able to formulate effective goals will have, no doubt, a major influence on the future success of their respective HCOs. In times of system turbulence, goal initiation is usually a far better alternative than goal response.

It should be noted initially that, as popular as the con- cept of SMART goals has become in recent years, it is also somewhat of a misnomer. The terms goals, sub-goals, and objectives are often used interchangeably, which has often been the source of unnecessary confusion, and as goal-set- ting theory continues to develop as a useful body of knowl- edge, related application benefits can be markedly improved when their differences are more clearly understood.

Together with an HCO’s mission, vision, strategies and tactics, goals and objectives serve as the foundation elements for most major programmatic initiatives.

An organization’s mission is basically its reason for being. Its vision describes where it wants to be in the future, and its values are a statement of the principles that form its moral foundation.5 Collectively, they are the basis for devising the supporting goals and objectives that assists

the organization in fulfilling its mission and realizing its vision.

Goals

Goals are the somewhat general ends toward which much more specific sub-goals or objectives are directed. This is where much of the confusion usually occurs. Goals and objectives are very different concepts, whereas sub- goals and objectives are basically the same things.

The popularized term, SMART goals, actually refers more to sub-goals and objectives than it does to the much broader term, goals. In the outline that follows, the term objectives is used because of its close association with Peter Drucker’s well-known practice of management by objectives (MBO),6 and because of its more practical use as a basic management skill. Some of the commonly recognized distinctions between goals and objectives include the following:

An HCO’s mission, vision, goals and objectives are inextricably related. They comprise the fundamental “what”

Difference Between Goals & Objectives

Goals Objectives Broad in scope Narrower in scope

General Specific

Intangible Tangible

Qualitative Quantitative

Abstract Concrete

End result Required steps

Hard to validate Easy to validate

Longer-term Shorter-term

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a host of performance improvement consultants.

Unfortunately, a successful goal setting process is not quite as simple as these examples might at first indicate. In the earlier development of goal theory, the terms goals and objectives were not always clearly distinguished and, as mentioned ear- lier, they are still used synonymously, which often presents problems.

As for the results of the Yale and Harvard studies, it has become increasingly clear that they are more likely the products of urban myth than of validated research.8 Nonetheless, there now exists a sub- stantial body of research that sup- ports a strong positive relationship between setting specific goals and achieving better outcomes.9

General vs. specific

Goals tend to be somewhat general, whereas objectives are much

challenging goals consistently out- performed those who were given vague, less challenging goals.

The Yale Goal Study surveyed 1953 Yale graduates, asking how many of them had specific written goals for their future. It was determined that three percent of them had such goals. A 20-year follow-up survey indicated that the three percent of students with specific written goals had accu- mulated more personal financial wealth than the other 97 percent of the class combined.

The Harvard study followed the 1979 Business School graduates and similarly found that only three percent of the graduates had specific written financial goals, but ended up making 10 times as much income as did the other 97 percent of the gradu- ating MBAs. The results of both the Yale and Harvard studies have been frequently referenced in management texts as well as in presentations by

of present and future organizational pursuits. Coupled with the “how” of strategies and tactics, they form the blueprint for the allocation of scarce economic resources.

Each element is important; how- ever objectives are the principal means through which they ultimately become operationalized. The careful design and strategic use of operational objectives are important leadership skills.

Goal theory SMART goals have become a

widely used management tool in many of today’s HCOs. Part of this popularity stems from the develop- ment of goal-setting theory during the latter part of the last century, part of it from the increasingly com- petitive need for greater intentional- ity, and part of it, no doubt, stems from the often cited findings of the 1953 Yale Goal Study as well as the 1979 Harvard Written Goal Study.

Earlier goal theory research by Latham and Locke7 involved extensive laboratory and field studies that clearly indicated that partici- pants who were given specific,

In order to reach a single goal, several enabling or supporting objectives usually have to be met. In health care settings, this involves the time and talents of trained professionals who function more on a collegial basis than in the superior-subordinate relationships.

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in terms of overall priorities. Lower priority objectives are pursued at the expense of addressing the higher, more important ones. The most straightforward way to ensure that objectives are relevant is through prior validation of the relationship of expected outcomes with the intended goals and then to list each objective in writing in their order of priority.

Time bound: Some versions of SMART goals list “timely” as the attribute represented by the letter T. In the out- line presented here, T indicates “time bound” which is considered to be more appropriate than “timely” in as much as timeliness is implied in the preceding “relevant” attribute (if an objective is truly relevant it is sine qua non, timely), and “time bound,” further makes it clear that the objectives are to be accomplished by an agreed-upon point in time. As soon as possible is simply not an acceptable timeframe. Without a predetermined deadline, there is only a general notion about due dates, which in turn generates a less than rigorous pursuit of closure. Where there is only a loose expectation of closure, priori- tizations and associated time manage- ment requirements are more apt to lack needed discipline.

Engaging: Adding engagement to the SMARTER objectives criteria is particularly relevant for the physician executive. Few things are more valu- able to busy clinicians than their time. Waste it once and second chances will be much harder to come by. Merely laying out a pre-established objective is not about to excite busy clinicians, nor will it promote a sense of partici- pation. Change theorists would be quick to point out that where there is

disagreements. Also implicit in the measurement criteria is the important concept of accountability. It is much more difficult to avoid accountability when measurement criteria are clear and not subject to interpretation.

Achievable: If the established objec- tives are not reasonably achievable with respect to available time, talent and resources, frustration is sure to follow. It is up to the physician execu- tive to set objectives that are realistic. This can be best accomplished through a process of negotiation and consensus. Comparative benchmarks from other similar organizations can also be help- ful. The use of “reach” objectives, which are a bit more ambitious, can be used as well, with the understanding that they exceed normal expectations and will require exceptional levels of effort and commitment.

Relevant: Few things are more frus- trating to organizational leadership than to observe busy professionals using up scarce resources without a clear direction. Too much time is spent “doing the wrong things right” or “being in the thick of some very thin issues.” It is natural for staff to focus on those things that they find interest- ing and enjoyable. Unfortunately those things might make only marginal con- tributions toward the more important, overarching goals. This can easily occur when goal relevance has not been made explicit. There is rationalized justifica- tion based mostly on the exertion of effort without sufficient validation that what is being done is, in fact, relevant.

A similar problem occurs when there is an absence of prioritization. When this occurs, efforts get focused on objectives that, although reason- ably relevant, are decidedly lower

more specific. Goal statements are typically formulated at higher, more strategic organizational levels, while objectives are geared more toward tangible, operational targets.

In order to reach a single goal, several enabling or supporting objec- tives usually have to be met. In health care settings, this involves the time and talents of trained profes- sionals who function more on a col- legial basis than in the superior-sub- ordinate relationships around which the MBO and SMART goal processes were originally developed.

The following SMARTER objec- tives criteria take this important dif- ference into account along with the substitution of the term objectives, which more accurately reflects the operational level of focus.

The first step in making SMART goals SMARTER is to refer to them as SMARTER objectives. Subsequent steps include the following:

Specific: Making objectives specific is an essential first step. It brings a much needed practical reality to distin- guishing effort from results. Effort, while indeed admirable, only amounts to a wheel spinning exercise if intended results do not follow. In the process, valuable time and resources are wasted. Committing objectives to writing in plain language leaves no doubt about exactly what needs to be accomplished.

Measurable: There is a long-standing saying in management circles that, “You can’t manage what you don’t measure.” Objectives should be quan- tified so that the degree of accom- plishment can be accurately mea- sured. Specific measurement criteria will eliminate the possibility of future

Motivational studies have demonstrated that rewards are essential factors in bringing about desired behavior.

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References:

1. Burns LR, Bradley EH, Weiner BJ. Health Care Management Organization Design & Behavior 6th ed. Clifton Park, NY: Delmar Learning; 2012.

2. Lee TH. Putting the Value Framework to Work. N Engl J Med 2010; 363:2481-2483.

3. Porter ME. What Is Value in health Care? N Engl J Med 2010; 363:2477-2482.

4. Bohmer MJ, Lee TH. The Shifting Mission of Health Care Delivery Organizations. N Engl J Med 2009; 361:551-553.

5. Griffith JR. White KR. The Well-Managed Healthcare Organization 6th ed. Chicago, IL: Health Administration Press; 2007.

6. Drucker PF. The Practice of Management. New York: Harper & Rowe, Publishers; 1954.

7. Latham GP, Locke EA. Goal setting – a motivational technique that works in Hackman JR, Lawler EE, Porter LW (Eds) Perspectives on behavior in organizations 1983 New York: McGraw Hill; 1983, pp. 296-304.

8. Fast Company Magazine. If Your Goal Is Success, Don’t Consult These Gurus. http://www.fastcompany.com/ magazine/06/cdu.html. Accessed August 8, 2011.

9. Borkowski N. Organizational Behavior, Theory, and Design in Health Care. Sudbury, MA: Jones and Bartlett Publishers; 2009

10. Kotter JP. Leading Change. Boston, MA: Harvard Business School Press; 1996.

11. Borkowski, N Organizational Behavior in Health Care 2nd ed Sudbury, MA: Jones and Bartlett publishers; 2011.

12. Lepnurum R. Cornerstones of Career Satisfaction in Medicine. Can J Psychol 2008; 51:40-45.

13. Ratanawongsa N, Howell EE, Wright SM. What motivates physicians throughout their careers in medicine? Compr Ther 2006; 32:210-217.

unlikely to work very well with medi- cal colleagues. Instead, SMARTER objectives rely on collegial relation- ships through which objectives are negotiated as a means of promoting “ownership” along with a sense of intellectual challenge and meaning- ful purpose. This approach takes more time and requires greater inter- personal skills; however it affords a much higher probability of success.

Pursuing well-defined objectives has not been without its critics. One major objection centers around prob- lems that result from focusing exclu- sively on fixed objectives in the midst of an uncertain and changing envi- ronment. The presence of conflict- ing objectives also poses potential problems, as does a failure to provide appropriate feedback.

To avoid these issues, physician executives should make sure that suf- ficient flexibility, intra-organization- al alignment, and real-time feedback are built into the design process. It is also important to ensure that all necessary support elements are in place. Without them, the objectives run the risk of being seen as unreal- istic, which will diminish chances for future staff engagement.

On the other hand, the careful design and implementation of well- constructed objectives will provide exceptionally valuable tools for improving say-do ratios and getting important things done on time.

Les MacLeod, EdD, MPH, FACHE, is a profes- sor of health management & policy at the University of New Hampshire in Durham, NH.

[email protected]

no “ownership” of an objective, mean- ingful stakeholder engagement will be difficult at best. In its absence, efforts to meet the intended objective more likely will be met with only tacit levels of acceptance or possibly some degree of resistance.10

A lack of involvement will almost certainly lead to a lack of engage- ment. A more effective approach is to involve clinicians in formulating the objectives from the very beginning. Describe the circumstances behind the intended objective and solicit cre- ative input. This will help to provide a much needed sense of “ownership” in both the objective and its achieve- ment. Ample evidence exists that confirms that individuals are much more likely to support those things they help to create. The proverb, “Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand,” has proven to be remarkably compatible with current change theory findings.

Rewarding: Motivational studies have demonstrated that rewards are essential factors in bringing about desired behavior. Motivation can be described as “the process through which unsatisfied needs and wants lead to drives that are aimed at goals or incentives.”11 Satisfaction of goals or wants is typically sought through various kinds of rewards that are either internal, external, or some combination of both. Current research suggests that physicians are motivated far more by internal rewards such as an intellectual chal- lenge, a meaningful purpose, and a sense of accomplishment.12,13

While much of what is used in an MBO process has been incor- porated into the SMARTER objec- tives approach, there are crucial differences that directly apply when working with physicians. The MBO process was designed for a superior- subordinate relationship that is

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