Six Steps to Address Unstructured Problems in Health Tourism Business Strategy

Unstructured Problems are those that are new or unusual and for which information is ambiguous or incomplete.

Problems that are hard to define. Problems where people and resources are at risk but you don't know where to start. Problems where guidance from an hired strategist may be helpful. In this article, I provide insight and tools that have a basis in real-life experience, not just armchair theory and cookie cutter recommendations.

In health tourism (medical, dental, therapeutic rehab, and substance abuse and behavioral rehab, and dialysis travel), destinations, health facilities and clinical practitioners (surgeons, consulting specialists, therapists) are confronted by a wide array of problems and situations, which require us to take action. Some problems are relatively straightforward or structured. Structured problems always have this clear connection between a finite set of solutions and outcomes that essentially occur every time.  

But what if the problem is related to a nascent and evolving service line of health tourism? Solving such unstructured problems on a constant basis is much of what managers do and the ability to solve them is what sets apart the best from the rest. 

When I am called upon to solve health tourism business development problems, I use tactics, strategies and workflows that are not taught in schools or in universities. It matters little if the client is a corporation or a small company, a state institution, a department, a political party or private equity investors - in order to be effective, I am forced to think where there is no box, take into account the interests of all the stakeholders involved and help them to not only build, but also to guide them through the process to execute on their strategy.

What separates me from other consultant strategists?

• Well, for one thing, I don't just make recommendations. I can also step in and "do" the operational parts. I know the workflows, the bottlenecks, and the risks. I don't simply correct errors, I predict them, run simulations for failure mode and effects analysis (FMEA), and establish the tactics to prevent errors from happening in the first place.
• For another thing, my experience and expertise is drawn from working in the industry before it had a name. Over the past three and a half decades I've hand my hand in operating a medical tourism business, building the largest provider network in the world, and observing and solving problems in 117 countries.
• For another, I've authored seven internationally-published professional development books for doctors, dentists, hospital and surgery center executives, thermal waters health resorts, and medical tourism marketing representatives, facilitators and case managers.
• For another, I designed the functionality around the world's first and only medical tourism patient care coordination and quotation management system - the Higowell Platform. The software has grown to over 1000 users in its first year. I also designed the functionality around the first health tourism bundled pricing engine that accurately and precisely helps healthcare executives and surgeons and clinic operators establish transparent package prices on a surgeon-by-surgeon, procedure-by-procedure basis. No smeared costs, no unexpected financial risks, no overlooked overheads.
• In my average work week, I actually work hands on as the director of business development for a surgical facility 18-24 hours per week. My tenure is on the line to produce content, script and direct videos, evaluate ads and ad placement, and select the advertising mediums (print, broadcast, out-of-home, and digital marketing and advertising for multiple campaigns across 14 surgical specialties. I produce results that meet or exceed targets and objectives and come up with new strategies and tactics to solve unstructured problems.

And it is from this background and work experience as an administrator, surgical nurse, health law paralegal and insurance plan contract negotiator and provider network developer that I write this article and share these practical tips today.

As a consulting strategist, I begin each new client project by listing to the clients objectives and goals. They are often the same at the highest level: 1) achieving tangible results, 2) teaching and coaching the project owner or manager and their organization, 3) building a larger sense of purpose or identification between the people who make up the organization, and 4) solving the problem by either correcting errors that have occurred or preventing them in the first place.  

In my first meetings with clients, often I am presented with economic, technical, and human capital issues that are quite complex or unstructured. By definition, they do not have a unique, “correct” solution.

These problems, can, in fact, have an infinite set of solutions and a very wide variety of outcomes. What I learn right away is how frustrated the highly intelligent and experienced project owner is because they already tried to fix the problem on their own but didn't produce the desired results. Therefore precious time has passed and they still aren't sure what to do. Unstructured problems are like that. Two similar problems may not respond to the same solution in the same way. One common problem is that talented and experienced managers start by applying last year’s (or decade’s) solution to today's problem. But the previously learned solution that was applied is no longer valid. When they call a department or team that provides "decision support" data and analyses, there are no such tools available that have already been packaged and tested or interpreted.

Unstructured problems within health tourism require a combination of fact based data analysis and highly subjective and even intuitive judgements about aspects of the problem. 

And let's face a tough fact: If you've come from outside of healthcare, whether the problem is one of marketing and advertising, clinical operations, or revenue management, if you've never spent a day walking in the shoes of the people who do these things, hands on, daily, exactly how intuitive is your judgement and problem solving capability?

I frequently am called to assist after other "consultants" and "certifiers" in health tourism facilitation, accreditation preparation, sales training, marketing, branding, and process engineering and work flows have departed and hauled away a wheelbarrow of cash and delivered little value. These new clients are left with a mess. The consultants were good at selling "solutions", but never have they been forced to "suffer" attempts to execute their impracticable (and often illegal) off the cuff recommendations. It would have been more precise to have sold a "theory" rather than a "solution".

They sell potentials and opportunities. If the client doesn't achieve its desired results and objectives - they blame the client for execution failure rather than their solution and guidance being impracticable. In that way, they go on to exploit and plunder other experts' research and recommendations they've only read about and proceed without the necessary experience and skills with the next clients on their list, armed with their copy/paste solutions portfolio.

I see this with medical tourism destination cluster development, accreditation and certification schemes, marketing and branding strategies, and even website design and content marketing strategies. In fact, I've seen my own materials on their slide deck without attribution or permission. They've lifted so many things from so many people that at some point it all gets jumbled together and they forget I am in the audience and that it's a derivative work of my original research, articles, diagrams, or other material(s) (and also of other experts) they are attempting to present (and rather poorly, I might add.)

Start from the beginning

To create strategies for unstructured problems in health tourism, I developed a process that effectively works in most assignments. The first phase is listening and defining the problem. A part of this is identifying and separating root causes from symptoms. There's an old axiom "Prescription without diagnosis is malpractice." It applies in this case.

Scope is a separate issue in that I must define the problem(s) in such a way as to actually be able to solve them in terms of authority and access to data. That's where practicability is put to the litmus test.

Here's a working example: If a novel infection is present in pandemic proportion that requires a specific protocol of PPE and techniques to treat and control further exposure, and my client doesn't have access to the necessary PPE and has never faced it before and therefore has no technique established, what can they do with what they have? Sound familiar? The client cannot simply shut the door and say, "Sorry, we don't have what we need so we can't help you." If we can't treat or solve the whole problem from its root cause, what can be solved to mitigate health tourism travel or treatment risk, package inclusion costs, competitive risks, quality and safety risks, reputational risks or something else?

So the question to ask at the end of the problem definition is this: What can I do to maximize improvement despite my lack of ____________________. Is that acceptable to the client?

And what will it cost them in terms of time, staff, and equipment or technologies, training, and financial resources. Those six meta budgets often are many multiples of my fee for my professional services. If the client cannot afford my fees and my travel costs, it is also likely they will not be able to afford the execution of ANY solution or recommendation.

WHAT TO LOOK FOR: Experienced consultants are able to assist the client to predict costs and meta budgets to execute. Those without this level of practical, hands-on experience who have never attempted to execute on their tactics and recommended strategies won't be able to give you the estimates for needed resources to execute. They'll equivocate and take no risk for accuracy or precision of their recommended solution as to time, skills, training, equipment or technologies, or budget required to execute.

READ ALL PROPOSALS CAREFULLY: What is their actual deliverable? Guidance or an actual outcome. Many of them leave before the execution problems arise. They don't remain long enough to see you through the solution or try a different approach. They write up their deliverable so that "they did their part". The problem is the problem is still unsolved.

That's usually when I get a first call for help. What's worse is that when I determine that their recommendations won't work, not ever, and I know why it won't work to produce the desired results or will waste precious resources, it is considered impolite and unprofessional to besmirch the other consultants' work product. So I have a new, additional unstructured problem: How to move the client forward to a solution and maximize any portion of the clients' previous investments from an inept and incompetent competitor - with a Mona Lisa smile and a pleasant attitude and keep my other more colorful thoughts to myself.

SECOND STEP

Selection of criteria: The key to successfully solving an unstructured problem is choosing which of all of the options important issues will really be priority or most critical in making a decision. Usually this includes one of the following: desired outcomes, some acceptable aspect of risk, and some things that rely on decision makers and other stakeholders.

THIRD STEP

Optional Alternatives: When one has a nearly infinite number of alternatives for an unstructured problem, I analyze along the lines of several basic types of alternatives. 

WHAT TO LOOK FOR: An experience consultant will be able to supply references and lessons learned "doing" the alternatives. An inexperienced consultant won't have a whole lot of alternatives to recommend because they are use to selling "one size fits most" copy-paste solutions and may name drop a lot with the assumption you'll never check references.

In health tourism, my most frequent assignment for an unstructured problem is patient targeting. The crux of the matter is a need for patient referrals and conversions to appointments for high dollar procedures.

Every health tourism facility or clinician wants to widen their catchment area for new patients and new business development. Among them, the following four candidates are pretty typical:

1. Some are perfect for this service line expansion.
2. And others should not enter health tourism with what they have to offer.
3. There are also others who should not pursue medical tourism because they are in the high 90th percentile of capacity with local patients and waiting lists. They have no excess capacity to sell without slighting local patients or pushing local access back.
4. Another category I've encountered are located in ecologically fragile environments where tourism is actively being limited or discouraged in the area; not encouraging medical and dental or other health tourism visitors.

The experienced consultant offers myriad alternatives when ethical to do so and is honest and secure to say, "I don't recommend this because in my professional opinion ..." The inexperienced consultant approaches the problem as a hammer, seeing every project as a nail.

Another way to approach may be a second level, deeper analysis before coming up with a recommended set of options. In each project assignment, I may develop a set of sub-alternatives within each alternative. I can handle them either as part of the Action Plan Creation in the final step or formulated as separate analyses before offering the execution plan. An experienced consultant may partially develop a few of the best alternatives for consideration in order to cover the most highly prioritized results desired by selecting criteria prior to fully developing the alternatives in order to limit the bias introduced.

I recently did this for a client who wanted to add cardiology and cardiovascular surgery service line with some out of town surgeons and cardiology specialists. The alternatives were 100% facility owned, or joint venture with the surgeons and specialists.

There were several options that met regulatory compliance requirements. But existing space limitations pending a new facility construction a few years in the future constrained the ability to install new technology needed for some procedures, namely procurement of a ceiling mounted C-arm, purchase of other portable ultrasound and Doppler and other equipment that was not already in hand, existing nursing staff training and development or decide to hire new staff with experience in these procedures, and radiology and sonography technicians who were presently only part time and called in when there were orthopedic procedures that required the use of moveable C-arm.

Pursuant to the preliminary decision of service line "ownership and management and investment, second level decisions for each alternative would include, among other things: a) who would pay the new equipment, b) who ould oversee the nursing staff and others who would be employed or contracted part time, c) who would fund the budget for ideation, design, and creation of marketing and advertising collateral, video, podcasts and graphics, d) who would execute and oversee marketing and advertising campaigns in house, e) who had the competency to analyze outcomes and renew advertising spend and placements, and f) where the funding for the advertising and marketing campaigns would come from.

There was also the matter of writing up the key components of the Memorandum of Agreement for the Joint Venture or 100% facility-owned approach which was impossible to draft without the preliminary decision, and impossible to negotiate and draft the terms and conditions for a) who contributes what in cash or in-kind investment, b) how long the first term period of the collaboration will run, c) what happens if the surgeons decide to go rogue and compete with the facility prematurely, before the first term is completed, and d) how non-compete terms and conditions will be spelled out.

Before medical tourism feasibility could be determined, or marketing strategies for medical tourism could be developed, market sizing beyond the initial market sizing analysis to simply establish the service line expansion was needed. Only then, once the "go/no go" decision was made for the local service line expansion could the expansion catchment area be defined for targeting and only after the parties determined which technology would fit in the existing space and which procedures would be available, could ideal client personas be developed so that market could be sized and evaluated and competitive analysis be carried out.

Is that an unstructured problem to be assigned to a novice generalist marketing consultant who doesn't know any of the clinical implications, compliance regulations, marketing and advertising regulations, and technology or operations implications? Not hardly!

A generalist marketer or novice consultant in medical tourism who sells marketing consulting would perhaps assume in error that all those decisions had been made. They would proceed to prescribe without diagnosis and just say "Do this" and start hammering on nails with SEO recommendations, and phrases such as, "You'll need a web page, a content marketing strategy and SEO treatments."

THE BEST APPROACH: Prioritize which criteria are most important and then choose which alternatives to develop further with second level research when it makes sense to do so.

FOURTH STEP

The fourth step in my approach for unstructured problem solving for health tourism is "analysis". Analysis in this context is looking at how the different alternatives can be evaluated using the criteria already selected. This may be more heavily weighted on numerical data or subjective data. The point of the exercise is to clearly establish the relative attractiveness of the different alternatives with respect to the criteria.

In previous example of the cardiology and cardiovascular service line expansion and then launching a medical tourism program for it, you can clearly see the stair step approach of first determining how the cardiology and cardiovascular service line expansion will be organized and launched de novo. If you don't have a cardiology and cardiovascular service line, you can't just build one just to offer medical tourism in that specialty, can you? The same holds true with robotic-assisted hip and knee arthroplasty launch and promotion for medical tourism.

What to analyze and in which priority is a challenge. The challenge is one of patience simply because someone hiring a consultant or a replacement consultant if the first one didn't work out leaves the client impatient, restless and dubious that their unstructured problem has a solution. And if it can be solved, how soon? And how much more will it cost in time, staffing, equipment and technology, and marketing and promotion to execute?

FIFTH STEP

Decision-making is the next logical step in the process of solving unstructured problems in health tourism. What I've learned is that if an analysis produces a very clear-cut answer, some key criteria that would reflect negatively on a preferred alternative, was likely omitted or overlooked or marginalized by bias. Unstructured problems generally are not so easy. Unlike the Occam's razor or the law of parsimony, "the simplest solution is not always the right one". Occam's razor says that when presented with competing hypotheses that make the same predictions, one should select the solution with the fewest assumptions.

Occam's razor was not intended as a way of choosing between hypotheses that make different predictions. Many clients get stuck on this with an unstructured problem because the view the majority of consultants as people who just borrow your watch to tell you what time it is. With unstructured problems, for each accepted explanation of a phenomenon, there may be an extremely large, perhaps even incomprehensible, number of possible and more complex alternatives that were analyzed in steps 3, 4 and 5. Often project owners that hire consultants prefer simpler recommendations instead of detailed accurate and precise recommendations because the simpler ones are easier to test - even if they are the wrong recommendations.

I frequently see this when being asked about national "cluster" formations for medical tourism. Some people view the world of medical tourism as a series of appointments to be completed on a trip to access healthcare far from home. They go about coordinating care by simply making reservations. Reservations for consultation appointment slots, hospital beds, operating theaters, hotel rooms and airline flights... and sightseeing excursions. They don't realize all the details that are necessary to pull the episode of care and travel together behind the scenes. They only appreciate that which is superficial at the surface. In the medical tourism industry there are clusters that are comprised of hotels and hospitals and others joining hands and incapable of doing more than joining hands because the working infrastructure was not part of the consultant's deliverable. But they are called "clusters" just the same.

The process I am describing here to solve for unstructured problems of health tourism are not a format for making managerial reports with focus on the positive aspects of a decision. Sometimes, the right decision is not to move forward. That's not the purpose of this six step process. Instead, the purpose is give the decision maker a tool to look carefully at the different aspects of a problem with as little bias as humanly possible and then to choose which of the criteria are really the most critical at this point in time.

In this case, the six step process forces decision makers or teams to deal openly and explicitly with all the issues involved. 

THE LAST STEP

The last and most important step in the process is to develop an action plan to execute on the decision taken. Clients make decisions which impact the business. Their success or failure has to do with their ability to make things happen. Some consultants use this as a way to place all blame for failure on the client that hired them. Other consultants, the ones with the operational experience beyond initial theory, tend to assist the client through the execution. They don't execute hands on, but they don't sign off until the job is done and outcomes can be evaluated. They remain on standby to help when course corrections are needed, and only bill for time actually working.

If the client desires exclusivity and the consultant is prohibited from taking on other clients while waiting, then a retainer is due and payable to cover the lost opportunity for the consultant to decline other assignments. That's a totally different discussion. Novice consultants without high demand may not be able to argue that remaining on unpaid standby necessitates a non-compete retainer.

Using the six-step process in a robust way, the manager will have identified the key issues involved in moving their decision ahead as part of the process itself. The idea then is to develop action plan steps, which maximize the positive aspects highlighted by the analysis, and mitigate the negatives. Sometimes the best option with unstructured problems is to develop a plan where Alternative 2 is a possible contingency plan if the first option doesn't produce desired results.

It is interesting to note how I got to this six-step process. Years ago, (ca 1990s) I was asked to address hospital financial executives on managed care exit strategies. Financial people and many hospital executives and board members along with many MBAs perceive the world and process decisions in terms of numbers. They naturally tend to bring their numerical training to bear on virtually every problem they encounter. The problem with the mindset is that there are normally aspects of unstructured business problems, which either cannot be quantified at all or can only be done so at the risk of oversimplification.  I knew this and was worried that in a CFO Forum. my style of presentation and thinking was not always numbers-based.

Teaching exit strategy for managed care contracts isn't straight forward. To develop a PowerPoint slide deck for my presentation would require me to explain that they would need to make many speculative assumptions and that many of their estimations, in the absence of data would be more like pure fiction and not even deserve the term ‘educated guesses’. 

I also knew that many didn't have the cost data and utilization data hidden anywhere. So to tell them to go get the data first would be a non-starter. That would be where I lost them in the program, at about slide three. My reputation as a speaker would be decimated in post program evaluations. So instead I went back to the key question in Step One, above: What can share and inspire to maximize improvement despite their lack of decision support data? I created a checklist of what to develop so that they could make better exit or renewal decisions. So in essence, I started by explaining the six steps, the supporting data that I would need if I were their consultant or manager, and how it could be created or built or requested and exactly what to ask for and from whom. I also explained why I suggested these certain data pulls so that if they were asked "Why do you need this?", they would be prepared.

I was also worried that because I tend to see the world in terms of forms, ideas, emotions, and feelings rather than numbers, they might dismiss my teaching because I didn't have the simple answer that lent itself to only numbers. In a managed care contract exit strategy, there's far more at stake than "if one is paid and how much and how much effort and cost there is to collect money owed.

By explaining the "why" and not just the how, and offering a step-by-step pathway educating them on "how" to think it through, rather than a list of "what to do", I was able to impress upon them that each hospital can have the same action plan  (Step 6), but that how they came to the decision (Step 5) was heavily dependent on the quality of how steps 1-2-3 and 4 were approached, which were not 100% numbers driven. They were "numbers informed."

The result of offering this six step process I've used most of my time working as a consultant and also as a business owner and as a hospital executive is that it can, if applied rigorously, effectively bridge the gap between the numbers people and the emotions people. In turn, the numerically oriented people can deal through the softer issues and the creative and emotional stakeholders to dredge through the boring numbers and analysis so they can feel better about their explicit leaps of faith. As a consultant, it's fun for me when I can watch the client organization make group based business decisions that enable and facilitate both types of people to actually communicate with one another in a positive, rigorous way and decide what is best for their business instead of being told some cookie cutter, copy/paste recommendation and walking away. It is also how I have maintained a loyal client base of customers that is counted in decades instead of months or weeks.

Do you need a strategy consultant for your medical tourism program? Perhaps you've been instructed to come up with a strategy for a solution to address an unstructured problem with operations, marketing or pricing. Or perhaps the issue is centered around clinical matters and patient safety for patients who will come from far away from your local catchment area. Perhaps you don't have time to research the matter yourself or you are concerned that you don't know what you don't know. What you do know is that what you are doing isn't working and that plan came from applying your best knowledge of other similar problems that didn't work as well as anticipated. Time constraints and limited practical knowledge are usually why a consultant is hired.

I am fortunate to have been in a front row seat to a lot of strategies. Some successful, others miserable failures. The reasons for the strategic failures can be internal, external or Black Swan events you never imagined would occur in your lifetime or career. Many strategies are doomed before they are executed because they are developed the wrong way. They failed to look forward and reason backwards. Consultants with the competence and experience can help you find shortcuts. They guide your thinking and help you take action after you decide based on the best data and alternatives you have in front of you. They guide what might need to be created first, in order to decide the best action plan.

As a dispassionate guide, I am able to look past the failures and walls my clients already experienced to the outcome they want. Then I reason backward from the outcome they wanted back to now. Part of this methodology comes from my situational awareness training early in my career. Part of my ability comes from my training in failure mode and effect analysis (FMEA) which is meant to mitigate risks and avoid failures.

Strategy starts when you look forward. The second part is reasoning backward. It is more complicated and challenging. Most people don't think to do things backwards. Reasoning backward tests your hypotheticals without actually making the mistakes in real life. It is a key to good strategy. When we reason backward and test the hypothesis, we end up with a better action plan in most cases.

Bur backwards reasoning is very complicated. It is unwieldy and takes more effort and more time that you may not have as a hospital executive, government authority or a surgeon. It takes practice to get it right. Without it, in medical tourism you'll be shooting in the dark and risk acting along a path that is indefensible. That has time, technology expenses, and other financial and staffing risk associated with it. You could take unnecessary risks, get you in regulatory compliance problems, patient safety problems or worse.

To understand why you or your previous consultant recommended a particular strategy, I examine your end game and reason backwards. When I do this, my clients avoid crises and they avoid desperate moves. They rarely want (or realize) one simple and straightforward result like "revenue" or "referrals". Instead they want revenue, referrals, brand reputation, and other measurable results. They want efficiencies and economies of scale wherever possible. They want all the things that advance their strategy. They want more than one way to win. They want pathways (plural) to success. They agree to tradeoffs in timing and expense and staffing and new purchases of technology.

I help my clients succeed. I help them make and defend critical choices. I help my clients prepare, evaluate options, competitors, markets, patient/consumer psychographics for health tourism and assess threats. This risk-based thinking is how we are trained in the operating theater. We think what's needed next in the surgery, we watch the entire situation, surgeon, assistant, anesthesiologist, circulating nurse, scheduling, time under anesthesia, bleeding, where we are standing, how we move within the sterile field what the rules are. All to get to the endgame: a positive surgical outcome and a happy and grateful patient. No complications, no post op infections, no unreasonable blood loss. An uneventful recovery. Each one is the result of a micro-strategy and backward reasoning, the risks that threaten endgame outcomes and what is needed to support the desired endgame. That's what strategy is -- to me. I use my strategy and my process to prioritize which intelligence I need to get my client to the deliverable they want, not the one I want them to choose. I know what I need in short order. Which things are work the effort and which aren't with the time, effort or cost.

I don't need to be the project owner. I don't need to make a slide with my medical tourism cluster conquests to sell more cookie cutter clusters. I don't need to impress anyone. I get as close to your desired results as possible with the greatest efficiency, lowest costs, and try to meet your objectives. I work within your hierarchy. I work side by side with your stakeholders. I've learned that different groups have different hierarchies for different decisions. One may be official, the other is operational. The official one decides personnel, strategic initiatives and resources made available. The official one decides whom to hire as the consultant. The operational folks decide on operational issues and acceptable moment-by-moment risks. Sometimes there's a conflict. In that case, I am a trained mediator so I mediate between the two to get resolution and consensus. (Usually operations prevails, by the way.)

The consultant that leaves to let you execute on your own after "they delivered what they contracted for" doesn't mediate because they are off with the next client and the next batch of cookies. It's kind of cyclical. I see where they are active and I know more or less where I'll be hired next.

I am a strategist when it comes to the clients accepted as well. I choose the projects and the clients carefully and decline the rest. I choose projects where the rewards are worth the risks. I choose projects where I can succeed and my client will be pleased. I really enjoy working on unstructured problems and creating strategic solutions. I enjoy playing the positive-sum and zero-sum games that are necessary and productive. I enjoy the ability to use my imagination and reason coupled with my experience. I enjoy strategy immensely, but I enjoy getting things done. The strategy is merely the beginning.

If you are interested in learning more about how I might help you develop a strategy for your medical or dental tourism business and help you work through the execution or a cluster development and launch strategy, please reach out by phone or by email. +1.800.727.4160 | linkedin@mercuryadvisorygroup.com I am available for a conference call during regular business hours, Monday - Friday USA mountain time zone. I have full service live answer telephone secretaries working 7 days a week, 24 hours per day to support me. You won't reach a voice mail recording when you call.