Replay: Goal Setting Methodology Objectives and Key Results (OKR’s)

Speaker 1: 0:16

Welcome to Beyond the Stethoscope final conversations with SHB. In this episode, jason and I sat down with Tyler Barnett and Matthew Nichols, phd, from University Hospitals in Cleveland, ohio, where they discussed the powerful goal-setting framework known as OKRs for objectives and key results. As leaders within the PopHealth and Analytics team at UH and expertise in OKRs, they dive deep into the OKR methodology, share specific examples of how UH has successfully implemented OKRs and provide insights on how your organizations can benefit from OKRs as well. So get ready for this vital conversation and join us as we explore the power of OKRs with Tyler and Matthew.

Speaker 2: 1:01

Hey everyone, this is Jason Crosby of Strategic Health Care Partners and your host for today’s episode. We are joined by Tyler Barnett, manager of Population Health and Data Science Analytics for University Hospitals in Cleveland Ohio. Matt Nichols, aco Reporting Analyst, also with UH. Today we’re going to discuss objectives and key results, also known as OKRs, goal-setting framework and leadership tool for those that are unfamiliar with it. So let’s just jump right in, tyler. Why don’t you start us off and give us some background on University Hospitals?

Speaker 3: 1:35

Thanks, jason. This is Tyler. University Hospitals is a large integrated academic and community health system in North Eastern Ohio. We have 21 hospitals, over 50 health centers and outpatient facilities, over 200 physician offices spread out through Northern Ohio. We are Cleveland’s hometown team, which is our commitment to the patients and community that we serve, or that University Hospitals serves, in North Eastern Ohio. For a bit of context and background, matt and myself work in University Hospitals Strategic Planning Office and we support the population, health and value-based initiatives of our health system as we are preparing for taking two-sided risk contracts with our various government and commercial payer partners and we use the OKR framework as our choice goal-setting approach for the many convoluted transformative efforts that we work on within the Office of Clinical Transformation under the leadership of Dr Peter Pronobost, our Chief Clinical Transformation and Quality Officer. Matt, anything to add about our institution perhaps?

Speaker 4: 3:17

our history. This is Matt, and I think what the one thing that was maybe left out there that makes University Hospitals relatively unique within the specific framework of our organization, is that we are really a collection of local hospitals, and so I’ve actually grown up, sort of born and bred in Northeast Ohio and have grown up in many of the counties that these hospitals served and have sort of watched the system at large, you know, acquire some of the smaller community hospitals and really organize the collective system into one focus, if you will. And so that really has led to the OKRs, to the use of the OKRs, and really speaks to a number of the efforts that Tyler and I are both involved in just relative to systemness and orientation around the system and how teams can leverage that orientation when they are setting goals, looking to improve performance and so forth.

Speaker 2: 4:26

Great, really helpful. Appreciate that and we’re glad to have someone you guys on the provider side and in a different market than some of our others, so we’re sure we’re going to get a pretty good perspective there. All right, now let’s dive right in. Ok, so Health Care’s Alphabet Soup we all know that. Let’s look at defining and clarifying, if you will, what is the framework that has OKR, and then the why and how you guys at university are leveraging that framework. We’ll start over with. Tyler.

Speaker 3: 4:58

From its origin, the OKR framework. We attribute all of our learnings directly to John Doar, who has leveraged he jokingly refers to himself as the Johnny Apple seed of OKRs. He’s spread it to companies such as Google, apple and a whole host of Silicon Valley tech companies as a deceptively simple, two-prong goal-setting framework that leverages both declaration of your overall objective, which went on appropriately, should be exciting and really show this is the destination of what we’re passionately here to accomplish, to just bring up an emotional excitement out of those who are working towards an objective and then a separate set of key results, which would be your measurement sticks or your milestones that are verifiably true whether or not you are making progress towards your objective. The whole framework is designed to be agile in nature so that you are constantly reviewing the key results you’re striving towards and then, on a recurrent basis, typically quarterly, adjusting your key results, learning why you did or did not meet those key results, to then make sure that you’re continuously accountable to set even further key results in the next quarter. The last component I’ll close in on on their introduction is the framework is designed to specifically allow yourself to set stretch goals, so the intention is to not meet 100 percent of your key results. In fact, that doesn’t really make it any different than any other goal-setting framework. Rather to set yourself for the best possible results you can strive for, with the understanding that you might not meet them all. Maybe you’ll meet 70 percent of your key results in a specific quarter, but hopefully that takes you farther towards your destination of what you are trying to achieve than if you set very realistic key results along the way. Similarly, I’ll share that they like to refer to the facts or the focus alignment, commitment, transparency and stretch. The FACTS is what we hope you remember in the alphabet soup, but in its totality. The reason why University Hospitals has chosen the OKR framework is because of the nature of our industry has a lot of people working on a lot of different projects and interdisciplinary or cross-functional roles and often very little clarity on what the overall organizational focus is that we are aligning our resources on. So we understand each other’s commitments with transparency such that we can stretch ourselves to really offer our patients the highest value services that we’re here to serve to our community.

Speaker 2: 8:37

So is OKR. Is it a new rollout or initiative of University, or is this something that has been going on for some time? How old is this used within the UH world?

Speaker 3: 8:50

It’s part of our overall ambition that we refer to as we want to believe, belong and build together. So first, we want to inspire the belief that we can actually make the patient health outcomes and patient safety issues that plague our industry. We really want to believe that each one of us individually actually belongs as part of the journey, if you will, to really make the change or the innovations that we’re here to serve at UH. And then the third piece of that us building together is the infrastructure of using objectives and key results to use objective measuring sticks to organize the insanity of all the different transformative and improvement initiatives we have in the system. So we’ve been using OKRs for about two years, but in the last six months, since August of 2022, we have really focused and zeroed in on this framework to manage our entire journey to Medicare break even initiative underneath this umbrella of the objectives and key results. So we can share examples, but there’s roughly 20 specific objectives with their key results that we’re measuring towards both to lower the total cost of care per discharge on the inpatient side and then lower the total cost per member per year on the accountable care organization side of our book of business.

Speaker 2: 10:51

So it sounds like it’s somewhat early in its use and adoption within the system, yet mature enough to where you guys are applying it on both a clinical quality and cost side, kind of a triple-aim partner in terms of how you’re utilizing it. So you mentioned a very applicable focus there the Medicare break even initiative. Any other areas of use within university that you guys can think of in this first two years where it’s been used?

Speaker 3: 11:24

Examples of different objectives we are striving towards. We are using the OKR framework to enhance our quality performance in our ACO contracts or Medicare shared savings program. To that note, uh is one of the top performing MSSP programs nationally year over year, which isn’t directly attributable to the OKR framework. However, our larger focus, if you will, of what the OKR is connected to definitely has a blend of Ractal management that that Matt can describe in more detail as well. But to list some more of those initiatives, we use the OKR framework for quality performance in our accountable care contracts. We’re leveraging it for improving our patient experience on all the different measurement systems that the health system is accountable for in their various programs. We’re using OKRs to redefine what we call our chronic disease systems of excellence, where we’re completely re-engineering the care continuum of how a primary care provider and a specialist coordinate to give the most excellent care for diabetes, copd, heart failure, hypertension and CKD. As early as this morning we had five clinical leadership teams physician dyads explaining to our weekly huddle where we review our OKRs. We brought in a physician dyad, both primary care provider and specialist, to explain their key results that they are striving towards to truly revolutionize the way that we offer our services for more preventive, proactive care supported by clinical practice guidelines and evidence-based medicine. But we use the OKR framework for their communication mechanism so that they can discuss the key results they’re striving towards, very similarly to another initiative that we have, which would be optimizing our appropriate SNF and IRF, or skilled nursing facility and inpatient rehab facility utilization, which is very critical to our value-based contracting performance. But, as I trust you all can understand, a very, very different initiative. There’s different stakeholders, there’s different operational components to how we optimize, better utilize our next site of care performance, and thus we use the exact same objective and key result framework so that the leaders in charge of that initiative have a similar communication structure to folks doing something such as reducing potentially avoidable ED utilization, which we have an objective of reducing by 10% in this year, and we have a series of key results across our primary care practices, our telehealth services and also within our urgent care offerings to help them. Those leaders understand the data that lives within the ACO world but that we can align on the set of key results to measure our capabilities to make it a 10% reduction in, hopefully, one year’s time on our potentially avoidable ED utilization performance.

Speaker 2: 15:26

There are more but I’ll stop there. That’s impressive In terms of you hear ED utilization, then you hear ACO contracts. You kind of hear, you think of those in polar opposites, almost in terms of the conversations you might have in our industry or folks you talk to. You normally wouldn’t even think of those in the same concept or thinking, even if it is a management framework. So now let me ask you guys, Matt and Tyler, what makes and the word of alphabets right. Oftentimes when I saw you guys come up with OKRs or using it, I tend to think of KPIs right. Or I’ve lived in the world of Six Sigma and Aaron, who’s with me, lives in the world of MIPS. There’s so many other quality-based, geared, milestone project management type orientations. What makes OKR different from some of these other goal-setting frameworks that you guys are using?

Speaker 4: 16:24

So I can comment on that, and certainly we’ve also been. I’ve been familiar with all of the other frameworks that you just mentioned and I think one of the interesting things with OKRs really is what OKRs are and what they are not. And so if we step back just a second and look sort of at the macro level OKR picture across our organization and, as we were speaking a little bit earlier about developing an enhanced level of systemness, okrs are a universal language for performance improvement. Kpis, or key performance indicators, are typically performance tracking, and so what OKRs allows us to do as an organization is to speak the same language around projects, as different as they may be. So we mentioned ED, reducing ED utilization or looking at our ACO contracting performance. We can use the same framework for vastly different performance improvement content and so forth, and so there is an obvious benefit there. There’s a leveraging that we can really tie into across, irregardless of the content of the performance improvement. Folks that I have either gotten very familiar with the OKR process and working through the OKR process, or are more familiar with, maybe, bits and pieces of it, or have some things that they have learned down the line. They can share those learnings across the organization again, irrespective of the content.

Speaker 3: 18:04

Build on that, if I can. What we found in the applied use of OKRs is that any one of the quality improvement frameworks whether it’s Lean, six Sigma, dmaic we use focus PDSA cycles within our quality institute here at UH. They’re phenomenal tools for defining and measuring improvement on known problems, but you only get incrementally better. They’re perfectly designed tools that I am a fan of and a practitioner of. Further, they solve problems in isolation and then they help healthcare get a little bit better at a particular performance indicator, whereas when we’re trying to completely transform or implement entirely different ways of designing our healthcare system. We chose the OKR framework because the health systems can no longer just make small improvements. We truly do need to look within ourselves and make 180 degree turns on some offerings that we provide to our community and our patients and our stakeholders. So what I like to share is a lot of KPI’s and different performance tracking tools that healthcare is very accustomed to are phenomenal, but what they kind of miss that objectives and key results help with is making that aspirational, exciting goal known in the objective to bring the joy back into our workplace when anyone could search backers or any listserv to see. The burnout rate in healthcare is intense and it’s a problem, and quality improvement is not necessarily the top funding mechanism coming into healthcare. However, using objectives to elicit the excitement of what we’re here to improve upon and then using key results to share our progressive milestones allows us to both excite ourselves but then also solve problems with visibility. There’s all a classic design statement that you don’t solve a problem in isolation, and that happens all too often in the silos of healthcare. So we’re using OKRs to get beyond breaking down silos and towards carving clear communication pathways across teams.

Speaker 2: 20:44

That sounds like as you were talking through that. Maybe think back quite a bit of ways. Project management and the PIMBOK project management book of knowledge but you always got was a little lear using it because it spoke in terms of several thousand hours and defining of a project in this large scope Sounds like with OKRs it’s not dependent on size of project and functionality of project. As Matt you’re just saying. You can hop between the utilization of ACO contracts. E-utilization can be several hour. Analytical project ACO reviews can be tons of hours. So with all that, can I speak to your point previously, matt, on downside and upside of OKRs and talk to us about some of the struggles Maybe you guys have seen while going through it as well over the last couple of years.

Speaker 4: 21:44

So I think the OKR framework being new within university hospitals and within the larger landscape of healthcare, that, or perhaps even the population health space that’s in a rapid state of flux right now, that’s another new tool. There’s a natural inclination to push back on one more new initiative, one more acronym, if you will. Tyler and I were actually in a meeting with a gentleman from ambulatory that’s been with the organization a little bit longer than we have. Then he pointed out the fractal management system. The OKR framework that you guys have already, or that the group is collectively embedded within the fractal management system, is the eighth iteration, the seventh or eighth management system that the system has rolled out in a given time period. There’s certainly those sorts of hurdles. I think some folks are suspicious of change or maybe apprehensive of change up front. If you layer that in with just constant change, there’s some suspect involved. So what Tyler and our group has been working towards is just getting out there, making it visible, educating folks again on what it is, what it is, not how flexible it is. One of the beauties of OKRs, at least in my mind, have been in several goal-setting activities, if you will, in this organization, in prior organizations that have leveraged things like KPIs or maybe a more traditional goal-setting framework. You sort of get stuck with okay, here’s what we want to do. How are we going to measure that? Well, maybe we don’t have a really great measurement for that, so should we reorient the goal? You sort of get buried into that measurement piece, whereas OKRs is just very different from that vantage point. It really comes up and says okay, where do we want to go Aspirationally, where do we want to go? And then how do we know that we’re going to get there? What are the key outcomes that are going to happen to tell us that we’ve basically arrived? And that’s very different than, okay, here’s a goal, here’s the activities. It’s sort of a three-step instead of a two-step and I find that very beneficial. But changes really can’t be understated within this space and it’s certainly a barrier and we have a large system. So there’s a lot of socializing of this framework to be had. Yet.

Speaker 2: 24:34

Yeah, always challenges with adopting something new, and especially if it’s a new management. Push out how maybe add to that, matt. Go back how was OKRs? How was it rolled out to university, to where? Because it sounds like now, after that initial period that you just covered, it feels like it’s successfully deployed, systematically, right. So, which is pretty phenomenal a couple of years within such a large organization, how has the deployment been? What was it like?

Speaker 4: 25:09

or what has it been like? I think Tyler could probably speak to that more pointedly than I could.

Speaker 3: 25:15

Our journey to OKRs at university hospitals was certainly spearheaded by our chief clinical transformation and quality officer. However, how we have essentially been working to infect the system with this thought process has been probably a two or three-prong approach. We had our call to action is the macroeconomic state of affairs in the United States. There’s so much pressure on health systems to remain financially viable and the impending transformation on a reimbursement mechanism is needed on a societal level. And so we have responded as an institution strategically saying we’re going to recognize that and we’re going to own our business through a management system, because management systems are quite lacking in health care. There’s some strong literature that suggests the level of accountability on the operational management side of health care is not as strong as it is in other high-rebel liability and industries, and so what we chose to do was address that macroeconomic reality and then, on a weekly clinical transformation huddle, we organized basically 20 teams that each have their own objective and key results they manage towards and they’re called in to report out on their progress towards their key results on a routine basis. So what we have there is our fearless leader saying this is the approach we would like to take from his level leadership, and then for the mid-level management, such as myself, what we have done is we have learned to teach and co-create objectives and key results with various different teams, to really partner with those teams so that the people who are leading their own strategies aren’t managing to a strategy that was written by somebody in the strategy office. The whole point there is that ideas are great but execution is everything. So those who execute on their key results should be the same people who write their key results. So to the question of how we’ve adopted OKRs far strong leadership from our C-suite and then partnered assistance from our analytics and our performance management teams to then go and meet with all of the stakeholders to work with them not to teach them the framework, but just start working on it with them. And the really exciting part of that journey is we get to watch folks who typically think through tasks and work output to manage towards. And that’s the most difficult part of the OKR framework is retraining your own brain to think not in terms of work output but in terms of outcomes that add value to our patients, to our payers, to our community and to our government. So we have a very clear value framework that we operate within, to define what value means to us, and then we leverage the OKR framework to set an exciting destination of where we’re trying to go and then the key results of how we’re trying to get there. An off-topic answer, but another example it becomes easier the more we practice the methodology. It becomes easier to the point where on Friday, I was called in to work with our Childhood Psychiatric Access Committee. I am not an expert in this space, but I can quickly meet with them and explain. Here’s how we’re using OKRs. Here’s a few examples of how we’re doing it in these other transformative initiatives within our institution. Here’s the philosophy. Here’s a template. If you write some OKRs, we can come back in three weeks to look at them to ensure that they are written to the specifications that that the Riggers philosophy hopes we use, and then within a month’s time where we can use that framework to improve upon our access for childhood psychiatric and psychology services.

Speaker 4: 30:20

One quick add to what Tyler’s already stated and maybe a bit of a plug to come back and talk with Jason and Erin again. But another way that OKRs have been socialized around the organization is sort of the reinforcement across multiple areas of engagement, one being the fractal management system which Tyler had alluded to previously. Quite frankly, a whole nother conversation of itself, but Tyler and I are both on that team as well and that is a system-wide management system and OKRs have found their way and certainly found their place within that system. Pillar one there’s four pillars and pillar one is declaring your goals, so that framework is available to folks as they work through that system and what that system does. Again, we’ve talked a little bit about systemness, generalizability of performance, improvement, frameworks across the organization. Fractal management the crux of it is looking at the organization as a system of systems born out of fractals which, if you’re familiar with fractals in nature and the biomimicry, space and all of that, fractals are a simple structure that are iterative and repeating and can really handle complexity quite beautifully. And so that what is naturally occurring in nature has been applied in a framework and has really allowed us a lens, if you will, to look at a system of 30,000 people and really break it out into systems and systems of systems and within the realm of performance improvement, looking at both who we may work with on a daily basis, but who we may want to engage across the organization that perhaps we don’t work with on a daily basis. Where are the content experts? Who has the content knowledge or who has the institutional knowledge to arrive at a better outcome with a particular performance improvement framework? So OKRs have a natural place within that fractal management system and that’s another way that we’ve reinforced its use, if you will.

Speaker 2: 32:28

Yeah, we’ll definitely carve out a part two of this and talk about that portion of it well. So a lot of our audience are your typical physician practice administrators. You’ve got hospital administrator CFOs and revenue cycle folks on those lines of work, maybe not at a university hospital health system size type of organization. So, talking to them for a second, where would you point our audience to first go learn a little bit more? Not that they haven’t learned enough from this podcast, obviously, but where they should go learn and maybe how best to go implement OKRs within their own organization, whether it is a small physician practice group or a lot of our audience is your typical critical access 25 bed type hospital. So, with that in mind, what suggestions would you give to them?

Speaker 3: 33:22

First and foremost, I would suggest going to YouTube. There are plenty of really great examples or different videos that John Dorr has in regards to the OKR framework. Bono is using OKRs across his foundations and can give very easy to understand examples of using the OKR framework, and there is a huge amount of content I would say outside of the health care complex but then within OKRs. I think my recommendation would be to try to bring an example from your own personal life, for example. A great example is if my objective is I want to improve my relationship with my kids in the mornings and my key results might be all right, I’m going to tickle them, I’m going to tell them three jokes before they get to school and we’re going to have breakfast together. The exciting part about that to me is you can verifiably measure whether or not you did those three key results within a week or two and then see if you’re getting any closer to your objective of just having more fun with your children in the mornings. I use that example because it helps me to see the agnostic capabilities of the framework can truly apply to anything that you are excited about and then throw down some measurements sticks of key results that you can verify whether or not you did or did not complete them. It’s remarkably simple, but it’s deceptively challenging sometimes to find the right words to include in both your objective or within your key results. So I think the best advice I’d have is to not trip over perfect to get to good enough and just pull out a sheet of paper, write down your objective of where you want to be with excitement, and then write down your key results. And then you can ask yourself there’s a series of questions that you can test yourself to make sure that your key results are verifiable, binary to the simplest point of saying yes or no, did I accomplish this or not? Which is remarkably difficult even for folks who have been managing performance improvement work in their whole careers. That astounds me at times when it seems so much more difficult than it really is.

Speaker 4: 35:58

The only thing I would add, there is the legacy that OKRs have. So we’re approaching nearly 60 years since its formal inception at Intel, and so there are a lot of industry-related anecdotes around OKRs, relative to Intel, apple, google and many others that I think have been very helpful in this journey, as Tyler and I have really both embraced the OKRs and have really become OKR students, if you will, to work through the process and, I think, to advance our own understanding and certainly be understanding of your organization. So plenty of content out there to peruse.

Speaker 2: 36:41

Folks are going to want to reach out and learn more. How do they do so? How can they find you guys and learn more about OKRs and maybe need to reach out to you?

Speaker 3: 36:49

They should reach out to strategic health care partners, or my contact information will be available Tyler Barnett LinkedIn profile. We have our email addresses posted and both Matt and myself have been consulting internally within UH with our OKRs and we’d be glad to discuss answer any questions, because we truly believe this is the right approach to solve the complexity that is delivering health care services in the United States.

Speaker 2: 37:26

You got it Well. Tell you what it’s great information, good conversation with our friends from Ohio. We can certainly go off another hour, so we’ll have to split this up in a part two, so hopefully our audience will tune in for that, as we talk more about fractal management and applicability of that system. And so we really appreciate Tyler and Matt joining us for part one, and we thank you listeners for joining, and we obviously always look forward to our next podcast and until then, everybody have a great rest of your day.

Speaker 1: 37:56

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Speaker 2: 38:04

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Speaker 2: 38:29

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Speaker 1: 38:33

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Speaker 2: 38:36

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Speaker 1: 38:41

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Speaker 2: 38:47

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