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6 Developing Strategic and Operational Plans
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To mean well is nothing without to do well.
—Plautus
Trinummus
Learning Objectives
After reading this chapter, you should be able to do the
following:
• Identify strategy concepts, including the components of
organizational strategy; generic strategies; diversi-
fication, integration, and implementation strategies; and blue
ocean strategy.
• Describe the use of strategies for large, multiunit
organizations, including the use of the Boston Consult-
ing Group matrix to discern strategic implications from the
analysis of existing operations, and the use of
product/market expansion strategies and diversification
strategies for organizational growth.
• Discuss tactical issues that are relevant to pursuing
participation in a managed-care network.
• Delineate the factors that influence the selection of a
strategy by an organization.

• Explain how operational plans support strategic plans, and
describe how operational plans are developed.
Section 6.1Strategy Concepts
Introduction
After developing a set of objectives for the time period covered
by the strategic plan, the strat-
egy necessary for accomplishing those objectives must be
formulated. First, planners must
design an overall strategy, and then define the operating details
of that strategy as it relates
to providing services, promoting operations, determining
locations, and increasing revenue
sources. This chapter introduces the concept of strategy, and
describes strategy elements,
approaches to strategy development, and how operational plans
support strategic plans.
6.1 Strategy Concepts
The word strategy has been used in a number of ways over the
years and especially so in
the context of business. As we discussed in Chapter 2, strategy
means leadership and may
be defined as the course of action taken by an organization to
achieve its objectives. It is a
description first in general terms and then, in increasingly
greater detail, of the activities
the organization will undertake to meet its goals and fulfill its
ongoing mission. Strategy
is the catalyst or dynamic element of managing that enables a
company to accomplish its
objectives.

Strategy development is both a science and an art, a product of
both logic and creativity. The
scientific aspect deals with assembling and allocating the
resources necessary to achieve
an organization’s objectives with emphasis on matching
organizational strengths with envi-
ronmental opportunities, while working within cost and time
constraints. The art of strat-
egy is mainly concerned with the effective use of resources,
including motivating people to
make the strategy work, while being sensitive to the
environmental forces that may affect
the organization’s performance and maintaining the ability to
adapt the HCO to these chang-
ing conditions.
Components of Organizational Strategy
The focus of strategy varies by the planning level: the
organization as a whole or a unit within
the organization. However, we can identify five components of
strategy that define strategy at
each level. The following list provides descriptions of these five
components.
1. Scope. The scope of an organization refers to the breadth of
its strategic domain—
the number and types of locations, services offered, and market
segments it com-
petes in or plans to enter. Decisions about an organization’s
strategic scope should
reflect management’s view of the firm’s vision, mission, and
value discipline. This
common thread among its various activities and product/markets
defines the essen-
tial nature of what its business is, what it should be, and how it
contributes value to

its customers.
2. Goals and objectives. Strategies should detail the desired
levels of accomplish-
ment for one or more dimensions of performance—such as
volume growth,
profit contribution, return on investment, and customer
satisfaction—over
specified time periods for each of those service areas and for
the organization as
a whole.
3. Resource deployments. Every organization has limited
financial and human
resources. Formulating a strategy also involves deciding how
those resources
are to be obtained and allocated—across locations, services
offered, market seg-
ments, functional departments, and activities within each
business or product/
market.
4. Identification of a sustainable competitive advantage. The
heart of any strategy is a
specification of how the organization will compete in each
service arena and prod-
uct/market within its domain. How can it position itself to
develop and sustain a
competitive advantage over current and potential competitors?
To answer such
questions, managers must examine the market opportunities in
each unit and prod-

uct/market and the company’s distinctive competencies or
strengths relative to its
competitors (that is, its differential advantage). Real
competitive advantages exist
only when all four qualifying conditions are met.
5. Synergy. Synergy exists when the organizational units,
product/markets, resource
deployments, and competencies complement and reinforce one
another. Synergy
enables the total performance of the related businesses to be
greater than it would
otherwise be: the whole becomes greater than the sum of its
parts.
Generic Strategies
Strategy options are the alternative courses of action evaluated
by management before a com-
mitment is made to a specific course of action, which is
eventually outlined in the strategic
plan. Thus, strategy is the link between objectives and results.
Designing strategies is a pro-
cess that involves (a) identifying strategic options, (b) assessing
options, and (c) selecting the
most appropriate strategy or strategies (“1993—A boom year,”
1993). Most companies have
growth as one of the basic objectives, so one area of strategy
development revolves around
the question of how growth will be obtained.
For the most part, an HCO can use one of the following four
basic, or generic, strate-
gies to accomplish its objectives. The two primary strategies are
broad differentiation
strategy and focused differentiation strategy. However, with
pressures from payers

and competitors now forcing an increased emphasis on cost
containment in the deliv-
ery of health services, overall low-cost strategy has also become
a basic and necessary
competitive strategy that applies to overall cost leadership. A
fourth generic strategy is
focused low-cost strategy, which is a low-cost strategy that
focuses on cost leadership for
a particular service or segment. In any case, the strategy
selected must be an outgrowth
of the organization’s basic vision and mission. The four
different generic strategies are
depicted in Figure 6.1.
Figure 6.1: Generic HCO strategies
Any of these four generic strategies, whether broad or focused,
can be used to accomplish objectives and
achieve results.
f06.01_MHA 626.ai
Value creation
emphasizing lowering
cost
P
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Value creation
emphasizing unique
differentiating features
Type of competitive advantage pursued
M
a
rk
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t
co
v
e
ra
g

e
Overall
low-cost
strategy
Focused
low-cost
strategy
Broad
differentiation
strategy
Focused
differentiation
strategy
Source: Adapted from Gamble, J. E., and Thompson, A. A. Jr.,
Essentials of Strategic Management: The Quest for
Competitive Advantage, McGraw-Hill-Irwin, 2009, p. 36.
Broad Differentiation Strategy
This strategy differentiates an HCO from other HCOs. An HCO
that pursues this strategy sees
that an important aspect of being able to fulfill its mission
involves cultivating the perception
of uniqueness in the minds of its service recipients and sponsors
regarding the HCO’s services
or products. In a sense, this means building brand loyalty so
that when patients or potential
patients think of a certain service, their first thought is of that
HCO.

For many HCOs, the broad differentiation strategy takes the
form of several distinct services,
each targeted to meet specific needs of patient groups in the
HCO’s service area. For example,
a medical group practice specializing in orthopedic services
could consider expanding the
number of programs it offers.
This medical group practice might seek to set itself apart from
its peers in the eyes of patients
by offering natural extensions of its current operations. Physical
therapy, outpatient rehabili-
tative medicine, or sports medicine services could be added to
the practice as part of a con-
tinuum of services for its patients. The patients would benefit
from the close coordination of
services and the convenience of multiple services, under one
roof. The medical group practice
would benefit from several additional sources of revenue.
By developing a reputation for high quality in programs such as
these, an HCO can come to
be associated in a positive way with certain types of needs for a
broad cross section of the
community. Becoming synonymous with quality services in the
public’s mind can enhance
the diversity and intensity of sources of revenue generation. The
end result of such differen-
tiation is a greater capability to fulfill the HCO’s mission
mandate in terms of its patient and
client needs.

For example, by using survey results to identify what was
important to its patients, Cleve-
land Clinic improved areas such as room cleanliness, the
medical staff ’s communication with
patients, and even the hospital’s noise level at night. These
differentiating factors improved
the hospital’s overall satisfaction rating from the 55th
percentile to the 92nd percentile for all
major hospitals in the United States in just four years (Merlino
& Raman, 2013).
Focused Differentiation Strategy
An HCO can also pursue its objectives by using a focused
differentiation strategy. This strategy
concentrates on a single service or a category of very similar
services offered by an HCO that
meets the needs of a specific group of patients/clients but still
seeks to differentiate the HCO
from its competition.
The Recreation Center for the Physically Limited employs a
focused differentiation strategy.
This center’s services are highly specialized: providing
recreational activities as a means of
enhancing the growth and well-being of its clients.
This center’s service recipients are tightly defined as well.
Recreational opportunities are
provided for the physically handicapped, excluding children
under the age of five. Using a
focused differentiation strategy, the recreation center seeks to
fill a service gap for the physi-
cally challenged in its community.
The main advantages of a focused differentiation strategy

include (a) capitalizing on the dis-
tinctive competencies of the people involved and (b)
concentrating on doing one thing well.
These advantages can also create a knowledge base of how to
carry out certain types of pro-
grams and improve efficiency in performing the services. An
example of a focused differentia-
tion strategy is in-home pharmaceutical services offered to non-
mobile patients. The chosen
segment must be big enough to justify the investment and
operating costs for serving the
segment. For for-profit organizations, it must also be a
profitable segment to serve.
Low-Cost Leadership Strategy
Another fundamental method for achieving objectives is a low-
cost leadership strategy,
which can involve either an overall low-cost strategy or a
focused low-cost strategy. The
hallmark of the low-cost leadership strategy is a major emphasis
on efficiency. By keeping
the lowest costs among providers in the HCO’s target region,
the organization is effectively
positioned to attract and maintain service recipients on the basis
of low pricing. The HCO is
also better positioned to match other providers’ pricing
strategies for extended periods, as
competitive bidding for major contracts becomes a way of life
in a managed-care industry
environment.
The use of the low-cost leadership strategy has its challenges.
Because the HCO is competing
basically on price, the organization must have a clear
understanding of its costs for rendering
its services. Administrative and indirect costs must be kept to a

minimum. With the use of the
low-cost leadership strategy, the services offered by an HCO
focus more on the fundamentals
and less on the frills. In the face of price competition,
differences between costs and rev-
enues—margins—are typically reduced with this strategy,
making higher volumes necessary
to maintain operating surpluses. All this requires an excellent
management information sys-
tem to track actual costs of care and revenues generated. An
overall low-cost strategy could
be adjusted for a focused low-cost strategy if lower costs are
achieved for a particular service
or segment in which the HCO competes with others that offer
similar services. An example of
a focused low-cost strategy is My Dentist Complete Care
Dentistry, which is a family of dental
practices in Arkansas, Kansas, Missouri, Oklahoma, and Texas.
My Dentist, which was founded
in 1983 by Pat Steffen, DDS, offers cleaning and exams for $39
and charges $99 for an extrac-
tion. Costs are kept low at My Dentist, while patients are
provided with quality care, because
several dentists operate out of the same facility, using a single
receptionist, insurance proces-
sor, and shared equipment.
Some of the low-cost leadership strategy’s operational demands,
such as large service vol-
umes, are beyond the capabilities of many stand-alone HCOs.
Those HCOs sometimes require

integrated relationships with other providers, which will be
either peers (horizontal integra-
tion) or organizations that provide other spectrums of care
(vertical integration).
Diversification Strategies
Several strategy options may supplement or complement the
basic, or generic, strategy cho-
sen by an HCO. These strategy options are usually referred to as
diversification strategies,
and they may take many forms. Great care must be exercised in
embarking on the usage of
these strategies because the use of some of them involves
entering a new business, which the
HCO may not be administratively or financially prepared to
manage. Summaries follow for
diversification strategies that include (a) integration strategies,
as well as strategies for imple-
menting integrated relationships, or implementation strategies,
which include (b) strategic
alliances, (c) joint ventures, and (d) mergers/acquisitions.
Integration Strategies
Integration strategies take two basic forms: horizontal
integration and vertical integra-
tion. Horizontal integration strategies take the form of alliances
between providers of similar
services, such as hospital groups. Vertical integration refers to
the major addition of services
closer to the client (forward vertical integration), such as when
a nursing home decides to add
home health services. It may also mean backward vertical
integration, where the added services
move away from the patient toward suppliers, such as in the
case of a large regional hospital that
contracts management services out to a small rural hospital,

hoping to draw patient referrals that
require more sophisticated treatment.
Achieving these integrated relationships can be accomplished
through a number of imple-
mentation strategies. These implementation strategies include
strategic alliances, joint ven-
tures, and mergers/acquisitions.
Strategic Alliances
Alliances are loose relationships among providers to achieve
certain common goals. While
contractual relationships are common, there is no exchange of
ownership or loss of ultimate
local autonomy. The organizations combining forces typically
are not directly competing
within a region.
Strategic alliances seek some of the economies of scale required
by the cost leadership strat-
egy by standardizing, for example, certain aspects of their
operations and combining their
purchasing power. These moves provide added negotiating clout
with suppliers of equipment
and materials as well as with suppliers of specialized consulting
and health program services.
One such alliance is VHA, Inc. VHA member facilities enjoy
such benefits as purchasing dis-
counts, access to consultants on operational issues, and
architectural services, among others.
HCOs may develop these alliances with suppliers to have an

assurance of supplies and to
achieve priority in order fulfillment with suppliers. For
example, a hospital may form an alli-
ance with an emergency care organization to staff their
emergency rooms instead of hiring
their own physicians. These emergency-care providers usually
provide separate patient bill-
ing and collection for rendered services.
Joint Ventures
In joint ventures, which are more formalized versions of
strategic alliances, two HCOs seek,
in various ways, to combine strengths and overcome the
weaknesses of their respective
organizations, often with some exchange or pooling of
management control of the venture.
HMOs are a prime example of this technique. Physician groups
and hospitals combine forces,
allowing the medical groups to better compete on a price basis
where services and risks
are spread over larger, combined patient volumes. The hospitals
benefit by solidifying their
patient referrals and gaining additional control over the costs of
care. In this vertical relation-
ship, both entities are better positioned to bid competitively for
the health services of large
employee groups.
Another example of joint ventures involves large, urban
hospitals providing management
contracts and specialist physicians for smaller, rural hospitals.
For example, DeSoto Regional
Health System in Mansfield, Louisiana (population 5,027) is a
38-bed acute-care hospital.
While the hospital is locally owned by the DeSoto Regional
Foundation, management is pro-

vided by Willis-Knighton Health System of Shreveport,
Louisiana, whose flagship hospital is a
902-bed general medical and surgical center.
Mergers/Acquisitions
Mergers/acquisitions, or merger arrangements, take the joint
venture a major step further.
Here, as in the joint venture, two organizations seek to do
better, together, what they had
been doing alone. With the merger/acquisition, however, the
separate organizations become
a single entity through some exchange of ownership. Typically,
the conditions driving such
a major ownership change portend dramatic, and often negative,
consequences, if ignored.
Market share, profitability, and organizational viability often
are threatened without some
major operational changes.
By combining resources and ownership, HCOs hope to achieve
greater efficiency through a
reduction in service duplication, improved and enlarged
geographic coverage, larger volumes
of care, and improvements in other critical operational aspects.
An example is Health Net’s
and Qual-Med’s $775 million merger in 1993 (H&HN Daily
Display, 2013). The combining of
their resources produced California’s largest, proprietary
managed-care organization, with
1.1 million enrollees.
Despite these potential benefits, successful mergers are difficult

to achieve. Autonomy and
managerial control are not given away lightly. Even where this
transition is successfully
negotiated, mergers often run afoul of the differences in
organizational cultures between the
merging partners. The differences can be so profound and the
personalities of the organiza-
tions so entrenched that mergers have failed to achieve
anticipated results on this basis alone.
One trend in mergers involves joint ventures of for-profit
hospitals with academic medical
centers. For example, LifePoint Hospitals, Inc., which is a
publicly traded company with 51
hospitals, has a joint venture agreement with Duke University
Health System. Similarly, Health
Management Associates has joint ventures with the University
of Florida and the University
of Mississippi Medical Center, while the Biomedical Research
Foundation Holding Company
operates LSU Health Sciences Center in Shreveport, Louisiana
(Blackmon, 2013) and a satel-
lite institution in Monroe, Louisiana (Weiner, 1994).
Acquisitions do not result in a new entity, but the acquiring
HCO does use its name on the
newly acquired organization. The acquired organization may be
left intact administratively,
with more general oversight provided by the parent
organization, or the parent organization
may staff the acquired organization with its own administrators.
Using a low-cost leadership strategy in an environment
dominated more and more by man-
aged care means partnering among service providers. The higher
overhead of stand-alone

organizations, the substantial financial risks of mistakes in
capitation expense and revenue
estimates in making competitive bids, and the bargaining power
with clients and suppliers of
larger competitor groups make it very difficult for individual
providers to effectively imple-
ment a cost/price leadership approach by themselves. Alliances,
joint ventures, or mergers/
acquisitions can provide a means for maintaining organizational
viability in the fast-changing
healthcare environment.
Blue Ocean Strategy
In their groundbreaking work, Blue Ocean Strategy, Kim and
Mauborgne (2005) describe
another approach to strategy that does not rely on the traditional
low-cost leadership, broad
differentiation, or focused differentiation strategies. Instead,
Kim and Mauborgne (2005)
suggest that industry assumptions be questioned and that firms
look for areas where demand
can be created and competition does not exist. They call such
competitive spaces blue oceans.
Blue oceans create demand, rather than fight over it. In contrast,
red oceans represent all the
industries in existence today that compete for the same
customers (or patients), using the
traditional low-cost leadership, broad differentiation, or focused
differentiation strategies.
Outperforming the competition in one or more of these areas is
the goal of a blue ocean
strategy (Kim & Mauborgne, 2004). Table 6.1 clarifies the
differences between red and blue
ocean strategies.

Table 6.1: Red ocean strategy versus blue ocean strategy
Red ocean strategy Blue ocean strategy
Compete in existing market space Create uncontested market
space
Beat the competition Make the competition irrelevant
Exploit existing demand Create and capture new demand
Make the value/cost tradeoff Break the value/cost tradeoff
Align the whole system of a company’s activities
with its strategic choice of differentiation or low
cost
Align the whole system of a company’s activities in
pursuit of differentiation and low cost
Source: Kim, W. C, & Mauborgne, R. (2004). Blue ocean
strategy. Harvard Business Review, (October), 76–84.
Blue ocean strategy involves increasing the value proposition
for the customer while simul-
taneously lowering costs, thus creating a new value curve, or
relationship between perfor-
mance of activities and the value received by consumers in
relation to competitors. Kim and
Mauborgne (2005, Spring) suggest that firms reference the
following four questions, which
are known as the Four Actions Framework, when they begin to
develop a blue ocean strategy:

1. Which of the factors that the industry takes for granted
should be eliminated?
Rationale for this question: The problem many industries face is
that certain
accepted practices no longer add value for the consumer, yet
everyone performs
these activities and competes with each other on the basis of
these activities.
2. Which factors should be reduced well below the industry’s
standard?
Rationale for this question: In many cases, firms have
overdesigned products or
services in their zeal to compete. The result is a product or
service that offers more
than customers want and that adds needlessly to cost.
3. Which factors should be raised well above the industry’s
standard?
Rationale for this question: The goal here is to eliminate the
compromises custom-
ers are forced to make.
4. Which factors should be created that the industry has never
offered?
Rationale for this question: This question forces the firm to
look at entirely new
value for customers and, thus, to create new demand (Kim &
Mauborgne, 2005,
Spring).
Consider the following example of the use, in effect, of a blue
ocean strategy by a healthcare
company. Danish insulin producer Novo Nordisk examined the
insulin industry and noticed

that the target market for insulin was patients’ doctors. The idea
was that the doctor had the
most influence on which insulin the patient purchased. Doctors,
for their part, wanted access
to a purer form of insulin. The 1980s saw a great deal of
progress on this front; now every-
one’s insulin was of comparable quality. As a result, insulin
suppliers had no way of effectively
competing on the basis of the product’s quality.
Novo Nordisk’s solution was to break with the industry standard
by shifting its marketing
from doctors to the patients themselves. The company explored
how insulin was sold in vials;
patients faced the challenge of dealing with syringes, needles,
and the insulin itself. In 1985,
Novo Nordisk developed the NovoPen. The device, which
looked like a fountain pen, allowed
Section 6.2Strategies for Large Multi-Unit Organizations
the patient to administer the insulin with one click and
contained a week’s worth of the drug.
Following this innovation, vials, syringes, and needles were
eliminated. By 1989 the com-
pany had developed the NovoJet—a disposable device even
easier to use than the NovoPen. In
1999, the Innovo came along, with a built-in memory that told
the patient the amount of the
dose, the amount of the last dose, and the time between doses.
In 2010, Novo Nordisk came
out with the NovoLog for type 1 diabetes.
By adopting a blue ocean strategy, Novo Nordisk became a

diabetes care company rather
than just an insulin producer. The company’s innovations
transformed the insulin indus-
try. Prefilled insulin devices are the primary way insulin is
delivered to diabetes patients
today. Novo Nordisk commands 60% of the insulin market in
Europe and 80% in Japan
(Gabel, Liston, Jensen, & Marsteller, 1994).
6.2 Strategies for Large Multi-Unit Organizations
As companies become more diversified and complex, the
industry analysis that is useful to
a single organizational unit operating in one industry becomes
less meaningful because of
multiple businesses operating in multiple industries. For
example, a large medical equipment
manufacturer may have several divisions catering to different
healthcare providers, such as
dentists, physicians, hospitals, and so forth. Each market has its
own characteristics and spe-
cialized equipment needs that should not be lumped together for
analysis.
The Boston Consulting Group Matrix
The Boston Consulting Group created a matrix that is a useful
tool for analyzing existing oper-
ating units or divisions of a large, complex organization. Using
this matrix involves the clas-
sification of operating units or services into one of four cells,
based on relative market share
and the growth rate of the market. Relative market share is an
organization’s share of a
given market compared to competitors’ shares. The growth rate
of the market is the annual
increase in revenues/patients in a market. The classification of a
unit into one of the four cells

has strategic implications for each of the units. The Boston
Consulting Group (BCG) matrix
is shown in Figure 6.2.
Stars are operating units that generate growth for the
organization. They are in service
areas that have a high growth rate, and they have a relatively
high market share. Stars may
require large infusions of cash to keep up with market growth.
When the market for these
units matures and market share is retained, stars become cash
cows. Cash cows are operat-
ing units with a relatively high market share, but they serve a
market that is not growing
rapidly. They provide the cash flow for the stars and the
resources to fix question marks.
Cash cows must be kept healthy and may require some
reinvestment to maintain that health.
Question marks are operating units that are in a rapidly growing
market but have a rela-
tively low market share. If successful strategies are put in place,
question marks have the
opportunity to become stars. Dogs are operating units with a
relatively low market share in
a low-growth market.
Figure 6.2: The Boston Consulting Group matrix
The matrix can be used to classify existing operating units or
services of an organization.
f06.01_MHA 626.ai

Relative market share
f06.02_MHA 626.ai
High Low
H
ig
h
Lo
w
M
a
rk
e
t
g
ro
w
th
r
a
te
Stars
Cash cows

Question marks
Dogs
Source: Adapted from The Boston Consulting Groups.
http://www.bcg.com/about_bcg/history/history_1968.aspx
One way to think about strategies for these four different types
of operating units is to envi-
sion a finance window with a line of business unit managers
lined up to ask for money. Which
ones should you give money to, if any? What amount of money
should each manager receive
to use in his or her specific unit? The BCG matrix would offer
the basic strategies shown in
Figure 6.2 to these operating units.
Basic Strategies for These Units
Based on the classification in the BCG matrix, there are strategy
implications for each of the
four quadrants of the matrix, which are shown in Figure 6.2.
These strategy implications are
overall for the business units, but should not be applied to every
unit in an HCO. Some units,
such as Imaging, may not generate enough revenue to cover all
costs (a dog) but are still nec-
essary for the operation of other profitable units.
http://www.bcg.com/about_bcg/history/history_1968.aspx
Growth Strategies
Most organizations have a desire to grow. Growth: (a) provides
opportunities for employees

to advance in the organization, (b) creates a bigger impact in
the market, and (c) may increase
an organization’s profitability. In addition to the strategies
derived from the BCG matrix, other
strategy alternatives can be used to help the stars grow and the
cash cows continue to keep
their market share.
While there are many possible growth strategies, this chapter
will discuss the following two:
1. Product/Market Expansion Strategies: market penetration,
product/service develop-
ment, and market development
2. Diversification Strategies
These growth strategies are illustrated in a 2×2 product/market
growth matrix, which is
shown in Figure 6.3.
Figure 6.3: Product/market growth matrix
Each strategy involves different types of growth opportunities.
Growth benefits an organization
by providing opportunities for employees, the ability to impact
the markets, and opportunities to
increase profit.
f06.01_MHA 626.ai
Products and Services
f06.03_MHA 626.ai
Existing New

N
e
w
E
xi
st
in
g
M
a
rk
e
ts
Market development
Market penetration
Diversification
Product development
Source: Adapted from H. I. Ansoff, Product/Market Opportunity
Matrix from Strategies for Diversification, Harvard
Business Review, 3, No. 5 (September–October 1957), p. 113–
124.

Product/Market Expansion Strategies
Product/market expansion strategies involve the following
growth opportunities: (a) pen-
etration of existing markets with existing products, (b)
development of new products aimed
at existing markets, (c) development of new markets for
existing products, and, finally,
(d) development of new products aimed at new markets
(diversification). Each of these stra-
tegic options carries with it advantages and risks as far as
management is concerned.
In a market penetration strategy, management has the advantage
of both product knowledge
and knowledge of existing markets. The obvious disadvantage is
the fact that the products
will eventually pass through various product life-cycle stages,
ending with sales decline and
extinction.
With a product/service development strategy, management has
the advantage of knowing
the market it is dealing with because the products or services
are aimed at existing markets.
A disadvantage for management is the lack of product or service
knowledge.
When a market development strategy is used, product
knowledge is the advantage, while a
lack of market knowledge is the disadvantage.
When a diversification strategy is used, managers are under the
most strain. They have nei-
ther product knowledge nor market knowledge as an advantage,
so they must quickly acquire

this knowledge or rely on hiring managers or on finding
companies that already possess the
sought-after product and market knowledge.
A brief summary follows for each of the following three
product/market expansion strategies,
which are shown in Figure 6.3 and which focus on growth
though (a) reaching the same mar-
kets with new products, (b) reaching new segments, or (c)
sampling increasing usage from
existing segments.
Market penetration is a strategy that involves growth through
increasing sales of existing
products in existing markets. This expansion of sales can come
about by (a) altering pur-
chase patterns of existing customers—getting them to buy more
when they purchase, or to
purchase more frequently; (b) attracting nonusers to purchase
the product; and (c) attract-
ing purchasers of competitors’ products to switch, thereby
increasing market share. Alterna-
tives (a) and (b) involve increasing the total size of the market,
while alternative (c) involves
increasing market share.
Product/service development is a strategy of increasing sales
through the introduction of new
products and services to existing markets. Product development
involves altering existing
products and services by (a) adding new features, (b) offering
different quality levels, or (c)
offering different sizes of the product.
Market development is a strategy that entails offering existing
products to new markets. These

markets can be (a) new geographical markets, such as foreign
countries; or (b) new market
segments not currently using the product.
Diversification Strategies
Diversification strategies, which have been previously discussed
in this chapter, are a final
strategic alternative for growth. Diversification entails
introducing new products into new
markets or acquiring firms that are already engaging in business
opportunities with those
new products or markets. Diversification strategies can take
various forms. The most com-
mon forms for diversification strategies are: (a)
product/technology-related, (b) market-
related, and (c) non-product/non-market-related. Diversification
strategies may involve stra-
tegic alliances, joint ventures, or mergers/acquisitions.
Diversification strategies are the most
difficult strategies to implement because the organization
seeking growth may have little or
no knowledge of the new market or the new product or service.
An example of this type of
situation might be a clinic that decides to enter the home health
market, which is a transac-
tion that requires new staff, new services, and knowledge of
new regulations.
Integrative Diversification Strategies
Another diversification growth strategy involves the integration
of activities within an HCO’s
current industry. The three alternatives for this type of growth

are: (a) forward integration,
(b) backward integration, and (c) horizontal integration.
Forward integration as a growth strategy means that the
company looks “down” the channel
of distribution to the next channel members who currently
represent a customer type. For
example, a manufacturer who “looks down the channel” sees
either wholesalers or retailers
as the next channel member. Thus, forward integration takes the
form of expanding—inter-
nally or through acquisitions—by the company taking over
wholesaling or retailing functions.
Backward integration as a growth strategy seeks growth through
the ownership of com-
panies that are “up the channel,” such as companies that are
suppliers of products or raw
materials. For example, a hospital might buy out a supplier of
gowns or other supplies that it
uses in its operation.
Organizations that do not want to acquire other organizations
through forward or backward
integration, both of which are a form of vertical integration, can
accomplish some of the bene-
fits of vertical integration through a concept called supply
chain, or value chain, management.
This involves focusing on managing the relationship among the
entire sequence or chain of
suppliers that are involved in creating or delivering a product.
This process affects relation-
ship with upstream suppliers and downstream users.
Effective supply chain management can create a competitive
advantage for a marketer through

the following means:
• Increased innovation
• Decreased costs
• Improved resolution of conflict among chain members
• Improved cooperation among members
Horizontal integration as a growth strategy seeks growth
through the ownership of com-
petitors. This strategy involves identifying and acquiring firms
that are in competition with
the company seeking growth, and it is a commonly used strategy
in the healthcare industry.
Section 6.4Factors Influencing Strategy Selection
Horizontal growth can also be achieved through strategic
alliances. A strategic alliance is a
partnership between companies to create a competitive
advantage. These relationships are
created to improve each partner’s ability to create or enhance
their competitive stance in
today’s fast-changing markets.
6.3 Tactical Issues
In 2012, the enrollment estimate for HMOs was 70.24 million
and PPOs, 245.84 million
(MCOL, n.d.). It is estimated that approximately 88% of
physicians have contracted with a
managed-care organization (“Majority of docs contract with
managed care,” 2009). Because
of this growth, a closer look at some special concerns in
pursuing participation in a managed-
care network is warranted.

Managed-care networks exist, fundamentally, to drive down
healthcare costs for large employ-
ers, consortiums of employers, and other groups capable of
wielding enough buying power
to engage the interests of health service providers. Most
providers do not control sufficient
service assets to compete alone in this new environment. This
constraint typically means
that providers must look to contracting with other providers or a
managed-care company
to compete.
Entering into managed-care agreements can be an essential
method for stabilizing income
sources for many HCOs. For the agreements to work, however,
there must be substantial and
equitable vested interests for all participants, so that the
organizations are committed and fully
engaged in the alliance. Mississippi Health Partners, which is a
physician–hospital alliance that
involves three hospitals and approximately 350 physicians,
provides an example. The hospitals
put up 50% of the roughly $1 million in seed money to establish
the alliance. Approximately
100 primary care physicians invested $1,100 apiece and another
200 specialists put up $1,500
each to match the hospitals’ contributions. The organization
uses two types of voting stock,
with the physicians holding ten votes of each type of stock and
the hospitals, six of each. Board
decisions are determined by a simple majority of each type of
stock (Gabel et al., 1994).
6.4 Factors Influencing Strategy Selection
At least four factors influence the choice of a strategy selected

by an organization: its inter-
nal resources, the distinctive competencies of its leaders and
staff, its stage in its life cycle,
and the strategies used by competing HCOs. There is no one
best strategy that will always
prove successful. Instead, the strategy that is chosen must be
the one that is best for the HCO,
given the nature of these four factors. Resources, for example,
may limit the organization to a
focused differentiation strategy. The organization may even be
an innovator in terms of ideas
but not have the financial, communications, or personnel
resources to offer other services.
As Chapter 2 emphasized, an HCO’s strategy must derive from
its organizational purpose and
objectives. If the organizational mission is focused on serving
needs of diverse groups, then
the organization’s strategy must be one that is compatible with
that mission. In other words,
what an organization does must be a function of what it is.
Section 6.5Operational Plans
The distinctive competencies of an HCO have a direct bearing
on the strategy selected. Distinc-
tive skills and experience in dealing with the physically
challenged, for example, can influence
strategy choice. Possession of these skills could mean the HCO
could target these individuals
as potential patients. These distinctive competencies are the
basis of doing things well.
The organization’s life-cycle stage is an additional factor

influencing strategy selection. For
example, an organization may begin with a focused
differentiation strategy but over time add
programs that serve more varied needs. Repositioning the
organization through introducing
new programs or serving new markets would be a pivotal point
in reformulating strategy. The
strategy selected must be given sufficient time to be
implemented and affect groups served,
but an obviously ineffective strategy should be changed. The
concept of changing an ineffective
strategy may seem self-evident, but resistance to change is
commonplace in many organizations.
The strategies competing HCOs use are another factor that
influences strategic choice. Pursu-
ing a copycat strategy may work in some cases, but positioning
an HCO among rival organi-
zations based on distinctive competencies is a much better way
to differentiate that HCO’s
offerings from its competition. For example, a competitor may
have already established itself
as the coronary specialist in a region. If so, that niche is
occupied, and it may be difficult to
recruit the staff needed to compete effectively in this specialty.
6.5 Operational Plans
Chapter 2 introduced a discussion about creating operational
plans. Aspects of that discus-
sion are restated and summarized, and then continued anew
here.
After all the planning steps are complete and a strategy has been
developed to meet the orga-
nization’s objectives and goals, it is time to develop an
operational, or action, plan. The opera-

tional plan represents the action or doing stage of strategy
implementation. Here, an HCO
serves, hires, fires, builds, advertises, and so forth. How many
times has a group of people
planned something with enthusiasm, only to see nothing
happen? This is usually because the
group did not complete an operational, or action, plan to
implement their strategy.
Operational plans need to be developed in all of the areas that
support the overall strategy.
These areas include service delivery operations,
communications, staffing, and finances. Each
of the more detailed operational plans is designed to spell out
what needs to happen in a
given area to implement the strategic plan.
The service delivery operations plan identifies exactly what
services will be provided to a spe-
cific group and the exact nature of those services. For example,
a home healthcare agency pur-
suing a differentiation strategy by expanding services must now
specify the limits of the new
offerings. Will the expanded services include rehabilitation, or,
possibly, hospice care, using
volunteers? Perhaps elder care will be offered or equipment
rental services will be added in-
house instead of being contracted.
The communications plan communicates the nature, location,
and time parameters of the program
to the intended audience and the rest of the HCO’s staff. This
plan needs to be well thought out
and carefully analyzed to avoid miscommunication or a lack of
communication. For example,

as part of its operations plan, a community rehabilitation center
needs a communication
strategy to provide information about its purpose and services.
Its communication strategy,
which follows, will involve three key elements: informing,
persuading, and reminding:
1. Informing—This involves providing information to
individuals and groups about the
organization. Specific elements of this plan call for the
following:
a. Use of video presentations and social media
b. Newsletters, pamphlets
c. Personal speaking appearances by executives or healthcare
professionals
d. Hosting luncheons/educational events
e. On-site visits by individuals/groups to the HCO
2. Persuading—This involves presenting the challenges and the
benefits of rehabilita-
tion, methods for dealing with these issues, and how the HCO’s
services deliver on
these issues.
a. Prepare application forms with which service recipients may
request additional
information or interested individuals may apply as volunteers.
b. Provide convenient means for patients to access services such
as transportation
services, if thereis a major need unfilled in
this area.

3. Reminding—This involves continuing the provision of
information to people already
familiar with the HCO so they will be constantly reminded of its
service capabilities.
a. Send letters/newsletters and other materials regularly.
b. Develop a complete file of individuals and
organizations by name for the future.
The staffing plan identifies who will carry out the activities
involved. Many HCOs must rely on
professionals to carry out plans, so it may be necessary to
develop a recruitment plan just to
staff the activity. Such a plan should consider the following
basic questions:
• What healthcare professionals will be needed to deliver
the services proposed?
• Can part-time staff or possibly independent contractors be
used?
• If temporaries will be used, what is the availability of
properly credentialed staff in
this category?
Finances must also be planned, usually in the form of a
financial budget. The budget is the
means to execute the plan. If the financial means to support the
plan are not available, then
the objectives must be adjusted. The budget and the operational
plan are in constant interplay.
Many people do not understand the budgeting process. Budgets
are a tool. Too often, how-
ever, the budget becomes the tail wagging the dog for the HCO.
“We put it in the budget so we

had better spend it” or “We had better add a little to this year’s
budget” are statements that
reflect this misunderstanding. Budget money must be tied
directly to performance. Perfor-
mance is measured against objectives. Key results and
objectives in an HCO’s operation need
to be prioritized. Money and resources are then allocated.
An example of this interplay can be reflected in this
hypothetical give-and-take regarding the
operation of a rehabilitation center. In a planning meeting, the
center’s leadership confronts
the realization that most of their resources for the next two
years will have to go into finishing
current building programs. Money is available only to maintain
the staffing status quo despite
the organization’s wish to expand the staff. That does not mean
that appropriate staffing levels are
not important—they are. The timing for expansion and growth
of the program, however, cannot come
until the other projects are completed.
Shown in Tables 6.2 and 6.3 are action, or operational, plans for
a large, professional phar-
macists’ group with several different types of services and
locations planned. The operational
plans in this example are related directly to the strategy to be
used and show the objectives
to be accomplished in a step-by-step fashion. This format forces
the planner to align objec-
tives, strategies, and action plans. Notice that the action-plan

format takes one objective out
of a five-year strategic plan and isolates it for further study and
analysis. In this case, it shows
the targets that this professional pharmacists’ group is aiming
toward in terms of pharmacy
operations and professional staff. Planners must make definitive
efforts to ensure that the
targets are clear and understood by everyone before action is
taken. It is important that all
those involved in executing a plan are aware of the plan and
involved in developing it. That is
the key to staff enthusiasm and support.
With targets, objectives, or goals in mind, managers agree on
various strategies. These strate-
gies are listed directly under the objectives. Next, planners list
all the actions that must take
place. Note the sections in which to record who is in charge, the
date started, and the date
completed. This document becomes not only a guide to action
but a timeline for starting and
completing plans.
The person(s) responsible for completing the actions in the
action plan and the expected
dates must be agreed on. All involved receive a copy of the
action plan, with their areas of
responsibility indicated. One person can coordinate a multitude
of projects and programs
because that individual has a clear record of what is to be done.
As each action or task is com-
pleted, the person responsible for the completion of the action
or task submits a completion
report to the coordinator. With this approach, the coordinator is
always aware of the project’s
or program’s status.

Periodic updates of the action plan are carried out so that
everyone sees the progress being
made. Once people become accustomed to using the action plan
format, which supports time-
saving and coordination efforts, they discipline themselves.
They do not want others to see
that they are falling behind.
Table 6.2: Action plan for opening new pharmacies
OBJECTIVE: To open seven new pharmacies within the next
five years (2014–2018).
Cumulatively:
2014: 1 pharmacy
2015: 2 pharmacies
2016: 3 pharmacies
2017: 5 pharmacies
2018: 7 pharmacies
STRATEGIES:
A. Explore financing options.
B. Hire marketing consulting firm to determine feasible
locations.
C. Select an architect.
D. Select a realtor.
(continued)
Table 6.2: Action plan for opening new pharmacies (continued)
Action Plan Person Responsible Start Date Date Completed

Contact 4–5 lending insti-
tutions for loan potential
and costs.
Network within profes-
sional associations for
marketing consultants and
architect candidates.
Set up architectural plan
review team.
Establish relationship with
realtor.
Table 6.3: Action plan for recruiting pharmacists
OBJECTIVE: To recruit 50 additional pharmacists within the
next five years (2014–2018) for placement at
our new locations.
Cumulatively:
2014: 6 pharmacists
2015: 16 pharmacists
STRATEGIES:
A. Make contact with pharmacist programs at nearby university
to determine recruiting potential and
procedures.
B. Develop informational/marketing brochure on current and
planned operations for use as a recruit-

ing tool.
Action Plan Person Responsible Start Date Date Completed
The assistant adminis-
trator will serve as the
primary recruiter.
The administrator will
appoint a selection team
to review and recommend
candidates, to the group’s
principals, who have been
screened by the primary
recruiter.
The assistant administra-
tor will set goals for the
number of organizations
to be contacted to become
part of the placement
network.
Summary and Resources
Chapter Summary
This chapter has concentrated on the development of strategic
and operational plans for an
HCO. Successful strategies tend to evolve over time as the
organization “goes up” the learning
curve of a given strategic plan, and the strategy is tweaked, or

adjusted, as feedback on the
success of the strategic plan dictates. Starting with Chapter 7,
the focus of this textbook will
be on the marketing of the HCO to position the organization and
reach the selected markets.
Key Points
1. Strategy is the course of action taken by an organization to
achieve its objectives.
Strategy begins as a general statement and becomes more
detailed as it addresses
the specific actions the organization will take to meet its goals.
Strategy is both a
science and an art. As a science, strategy deals with assembling
and allocating the
resources necessary to achieve the organization’s objectives,
matching organiza-
tional strengths with environmental opportunities. The art of
strategy is concerned
with motivating people to make the strategy work, being
sensitive to the environ-
mental forces that may affect the organization’s performance,
and being able to
adapt the HCO to rapidly changing conditions.
Five components of strategy are important to
remember. These are scope,
goals and objectives, resource deployments, identification of a
sustainable competi-
tive advantage, and synergy. Scope refers to such factors as
types of services offered,
number of locations, and market segments in which the HCO
competes. Goals and
objectives are specific, desired levels of accomplishment that
can be measured
over a definite time period. Resource deployment refers to the

use of financial and
human resources, which are always limited. Therefore, choices
have to be made
about how to best use these resources to achieve the
organization’s strategic objec-
tives. To effectively compete in the long term, the organization
needs to identify its
sustainable competitive advantage. This sustainable advantage
needs to be identi-
fied in each area in which the firm competes. Synergy exists in
an organization when
the organizational units, product/markets, resource
deployments, and competen-
cies complement and reinforce one another: the different
departments or units are
mutually supportive, and everyone works together toward the
same goal.
Four generic strategies apply to almost all
strategic decisions. The first is the
broad differentiation strategy. The objective of this strategy is
to distinguish an HCO
from competing HCOs. The broad differentiation strategy sets
the HCO apart from its
competitors, increases patient loyalty, develops a recognizable
brand, and reduces
price competition. A second generic strategy is the focused
differentiation strategy.
This is similar to the broad differentiation strategy, except that
the HCO is focused
on a more narrow market. In other words, the HCO chooses a
market where it is
particularly competitive and allocates the bulk of its resources
toward that market.
Finally, low-cost leadership is a strategy where the organization
controls its costs,
which it can then pass on to patients or receive a higher return

on money invested.
The HCO can have a focused low-cost strategy when lower
costs can be achieved
for a particular service or segment of the operation. It is
important to note that the
strategy is low-cost leadership. An organization must
understand and control its
costs before it attempts to compete on price.
2. Other strategy options include strategic alliances, joint
ventures, and mergers/
acquisitions. Strategic alliances are loose relationships among
providers to achieve
certain common goals. While contractual relationships are
common, there is no
exchange of ownership or loss of ultimate local autonomy. Joint
ventures are more
formalized versions of strategic alliances where two HCOs seek
in various ways to
combine strengths and overcome the weaknesses of their
respective organizations,
often with some exchange or pooling of management control of
the venture. Merg-
ers/acquisitions take the joint venture a major step further.
Here, as in the joint ven-
ture, two organizations seek to do better together what each had
been doing alone.
With the merger/acquisition, however, the separate
organizations become a single
entity through some exchange of ownership.
3. An alternative to the generic strategies is the blue ocean

strategy. Blue ocean strate-
gies create uncontested market space rather than attempting to
beat the competi-
tion in existing markets. Further, blue ocean strategy involves
creating new demand.
Primarily, blue ocean strategy posits that the organization
pursue a differentiation
and a low-cost leadership strategy instead of choosing between
a differentiation or a
low-cost leadership strategy.
4. The BCG matrix is another way to analyze products and
services. This 2×2 matrix
divides products and services into four categories: stars, cash
cows, question marks,
and dogs. Stars are products or services that have a high market
share combined
with high growth. Cash cows have a high market share but are
at the mature stage
of the product life cycle. Cash cows contribute cash flow for the
organization. Ques-
tion marks have a high growth rate and a low market share.
Question marks must be
monitored to determine whether they require new investment or
need to be ter-
minated. Dogs are products and/or services that have a low
market share and low
growth. Often, it is wise to divest dogs.
5. One way to view the opportunities available to an
organization is to use the prod-
uct/market growth matrix. This 2×2 matrix looks at new and
existing markets and
products. The organization can decide to sell more of an
existing product or service
to the markets currently served (market penetration), develop

new markets for cur-
rent products and services (market development), design new
products/services for
existing markets (product development), or develop new
products/services for new
markets (diversification). These growth opportunities are known
as product/mar-
ket expansion strategies.
6. Additional growth strategies include integrative
diversification strategies. Integra-
tive strategies involve growing the organization through
integration within the cur-
rent industry. One such action is forward integration, where the
organization looks
at ways to get closer to the end consumer. For example, a
compounding pharmacy
may decide to acquire its retail customers. Backward integration
looks back toward
vendors, manufacturers, and other suppliers. The recent
acquisition of physician
practices by hospitals is backward integration because the
physicians in those prac-
tices supplied patients and medical services to the hospital.
Finally, horizontal inte-
gration occurs when one organization acquires competitors or
enters into strategic
alliances with them. One example discussed in this chapter is
the strategic alliance
between LifePoint Hospitals, Inc. and Duke University Health
System.
7. Operational plans are the action steps that the organization
needs to take to activate
the chosen strategic goals. The operations plan details exactly
what services will

be provided to each specific group and the nature of the services
offered. Opera-
tional plans need to be developed in all areas that support the
overall strategy. Each
operational plan should have a timeline for completion and a
designated person or
committee responsible for its completion. Events rarely go as
planned, so there is
a need for senior management to update the plan for changes in
the environment
and to keep everyone informed of the progress the organization
is making toward
achieving its goals.
8. Operational plans need to address service delivery
operations, communications,
staffing, and finances. Each unit needs to identify its target
market and indicate how
it will reach that market and offer its services. Additionally, the
operational plan
needs to be communicated to everyone in the organization as
well as any involved
stakeholders, such as vendors. Often people will need to be told
more than once
about the operational plan, and reluctant staff will need to be
persuaded to par-
ticipate in the plan. Human resources will also need to develop
a plan to staff the
organization for achievement of its objectives. For example, if
one of the objectives is
to increase the number of patients in the maternity unit, a

sufficient number of OB-
GYN doctors and nurses will need to be hired or contracted.
Finally, money needs
to be allocated to achieve the strategic plan. Money is always a
limited resource,
so the proper budgeting for the implementation of the strategic
plan is of upmost
importance.
Key Terms
backward integration A growth strategy
that a company uses to identify possible
areas of growth by looking up the channel
of distribution toward ownership of other
companies.
blue ocean strategy Attempts to create
demand, rather than fight over it. Firms look
for areas where demand can be created and
competition does not exist.
Boston Consulting Group (BCG) matrix
A useful tool for analyzing existing operating
units or divisions of a large, complex organi-
zation. Using this matrix involves classifying
operating units/services into one of four
cells, based on relative market share and the
growth rate of the market.
broad differentiation strategy
Cultivates the perception of uniqueness in
the minds of an HCO’s service recipients and
sponsors regarding that HCO’s services or
products.
focused differentiation strategy

Concentrates on a single service or category
of very similar services offered by an HCO
that meets the needs of a specific group of
patients/clients but still seeks to differenti-
ate the HCO from its competition.
forward integration A growth strategy
that a company uses to anticipate possible
areas of expansion by looking down the
channel of distribution toward other cus-
tomer types.
horizontal integration A combining of
HCOs that are performing similar tasks. For
example, one hospital merges with another
hospital.
integration strategies Strategies that seek
to integrate one HCO’s activities with those
of another HCO to generate operating advan-
tages for both organizations.
joint ventures More formalized versions
of strategic alliances; in a joint venture,
two organizations seek in various ways to
combine strengths and overcome the weak-
nesses of their respective organizations,
often with some exchange or pooling of
management control of the venture.
Critical Thinking Questions

1. How could a dental practice implement a focused
differentiation strategy? Who
would the practice target and how?
2. Could a pharmacy use a blue ocean strategy in its operating
area? What services and
products could they offer to create demand?
3. What are the basic differences between a strategic plan and
an operating plan?
low-cost leadership strategy A strat-
egy with a major emphasis on efficiency. By
keeping the lowest costs among providers in
the HCO’s target region, the organization is
effectively positioned to attract and maintain
service recipients on the basis of low pricing.
mergers/acquisitions Take the joint ven-
ture a major step further. Here, as in the joint
venture, two organizations seek to do better
together what each had been doing alone.
With the merger/acquisition, however, the
separate organizations become a single
entity through some exchange of ownership.
product/market growth matrix A 2×2
matrix, which looks at new and existing mar-
kets and products and offers four strategies
for growth: market penetration, market
development, product development, and
diversification.
relative market share An organization’s
share of a given market compared to com-

petitors’ shares.
strategic alliances Loose relationships
among providers to achieve certain, com-
mon goals. While contractual relationships
are common, there is no exchange of owner-
ship or loss of ultimate local autonomy.
vertical integration Focuses on the sup-
pliers and end users of medical services to
combine operations with those HCOs. For
example, a hospital may contract with an
urgent care center to provide medical staff.

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