Jeff Hunter's argument starts with a translation problem. When the Japanese term hoshin kanri came into English, it first became "policy deployment," which never stuck, and then "strategy deployment," which did. Hunter's claim is that somewhere in that translation, organizations lost the essence of strategy itself. Strategy is about making choices — choices about what will make an organization unique in a way that genuinely matters to customers. Strip the choice-making out, and what's left is deployment of something that isn't really strategy at all.
He has watched this play out in healthcare specifically, and he named four recurring failures. The lack of choice-making creates overburden — every priority gets labeled strategic, and the organization tries to be all things to all people at once. Strategic plans start to look alike: improve safety, quality, patient satisfaction, employee engagement, financial performance, and grow, all simultaneously, even while pursuing population health management that is supposed to reduce demand for care. When every organization in an industry pursues the same strategy, they manufacture a commodity market and then feel, painfully, that they're being judged on price in what should be the most personal of businesses. Without real choices, catchball breaks down and the organization spreads confusion instead of alignment. And because the strategies are broad and span three-to-five-year horizons, rapid learning cycles become impossible — and without quick learning, the organization grinds to a halt.
This session reframes strategy deployment as a continuous learning system built on experimentation, customer insight, and alignment — not a fixed plan, not a periodic event. The school of thought is grounded in Hunter's own experience, and he was candid that the old approach he is critiquing is the one he ran himself for years.
Jeff Hunter is President of Jeff Hunter Strategy, LLC. Before founding the firm after retiring, he spent nearly 25 years as a senior vice president at ThedaCare, the health system in Wisconsin, with responsibility for staff functions including strategy formulation and deployment.
Hunter has a particular interest in facilitating strategic thinking for "professional organizations" — healthcare, higher education, service organizations, and not-for-profit community agencies. He is a faculty member at Catalysis (formerly the ThedaCare Center for Healthcare Value) and at the Donald J. Schneider School of Business and Economics at St. Norbert College, and a Strategic Planning Fellow for Sg2, a healthcare intelligence, analytics, and consulting firm. He is the author of "Patient-Centered Strategy: A Learning System for Better Care," published by Catalysis in 2018. He holds a BS in economics from the University of Detroit and an MA in health services administration from the University of Wisconsin-Madison.
Hunter's perspective was shaped by his ThedaCare years, by his consulting work with healthcare and non-healthcare organizations since, and heavily by watching how innovators use design thinking to disrupt the healthcare industry. Host Mark Graban and Hunter are both Catalysis faculty, and Graban introduced him as someone he had seen teach and speak many times.
Hunter used the Shingo Model as his frame: mental models shape the principles and behaviors of leaders, those principles and behaviors create systems, and those systems carry tools that produce results. His point about himself was direct — his old mental model created the old systems and the old tools, and he used those tools for a very long time. At one point he ran a management-by-objectives program that came straight out of that old model: the belief that the organization could command and control its own behavior, and the environment around it.
The old mental model viewed the organization like a biological body. The brain at the center thinks up all the answers and communicates them through the nervous system, and everyone inside and outside the organization does what was predicted and predetermined. That model cast the leader as the problem-solver — the people who solved the biggest problems best became the leaders. So Hunter's job, as he described it, was to conduct business from his office, have people bring him their problems, and solve almost all of them. There was no shortage of demand. Most of the problems he solved over those years came down to one question: what are we going to buy next and build next, to keep up with demand and revenue?
That generated a long list of possible strategies. As a planner, Hunter's job was to record all of them and take them to the board — usually around 200 to 250 items. The board would say, reliably, that you can't do 250 things, you should focus on three to five. So Hunter's actual job became inventing three to five labels under which all 250 items could be parked. He was unsparing about what that produced: planning as an event, something done every three to five years, or compressed to a one-year cycle while still trying to predict and predetermine everything the organization would do over the next several years. The old mental model led to the old tools, and the old tools no longer worked against the new kind of competitor.
Putting the strategy back into strategy deployment requires new mental models, starting with the nature of strategy itself. Strategy is about doing something that makes the organization different — choosing a different set of activities, and doing it through process. Three things are bundled into that: strategy is making choices, it is creating differentiation, and the differentiation comes through process, through what the organization does differently from competitors in a way that creates value in customers' eyes.
The second shift is the nature of strategic planning. Planning happens under conditions of uncertainty and competition. If you take systems thinking seriously — and it has been around since the 1980s — then the moment you do something, you have changed the game. There is no perfect information. You cannot fully command and control your own organization, let alone the environment around it. That makes planning a learning exercise.
Hunter reframed the term "learning organization." He used to think a learning organization was an organization full of people who like to learn — and who doesn't like to learn? But that isn't it. A learning organization is one that is good at learning what is creating value and what isn't, and at building the knowledge management systems to do that. Done well, that learning capability itself becomes a source of competitive advantage.
Hunter illustrated the shift with two stories that sit deliberately side by side.
The first is Webvan — the early online grocery delivery company. Webvan was very well capitalized, brought in a CEO from Accenture, and spent money on cutting-edge market research to segment and size the market of people willing to order groceries online. On the strength of that sizing, it built hundreds of thousands of square feet of warehouse space and bought a fleet of delivery vans — and went bankrupt within months. It had oversized the solution. The contrast Hunter drew, from Steve Blank's work on customer development and design thinking: start from deep customer insight, develop hypothetical solutions, and test them with a Minimum Viable Product, building out through learning loops.
The second story is the one that made it real for Hunter. Right before he left ThedaCare, a rural hospital administrator called him. The administrator thought patients weren't coming up to the hospital from one community because of a transportation problem, and proposed buying a van, tricking it out, hiring a driver, doing the marketing, and running a transportation service.
In the old mental model, Hunter knew exactly what would have happened. Market research first — three months. Then, because this was a roughly $100,000 idea, a business plan up the chain of command — another four months. Maybe in seven or eight months the administrator would learn whether the $100,000 was approved. Instead, on that same phone call, all Hunter had to say was: I don't know, that could be a good idea — what must be true for it to work? Because you can clearly buy a van and find a driver. The administrator immediately identified it himself: the whole hypothesis depended on whether people would actually use the service, and that was the critical assumption he didn't know the answer to. Hunter asked whether there was a fast, cheap way to test that assumption. There was — a local transportation service the hospital could rent on a per-use basis. The administrator ran that experiment, found people didn't use it in the volumes he had hoped, pivoted, and moved on to his next idea. He avoided overbuilding and avoided the waste of seven months of planning.
Hunter offered a way to categorize organizational work, because healthcare organizations are complex, operate in turbulent environments, and juggle the expectations of many stakeholders.
People come to work every day with jobs to do. Improving the process by which they do those jobs is operational effectiveness — taking a current standard and making it better, whether incrementally or in real stepwise improvement.
Then there are what Hunter called "big rocks" — big projects that consume cross-organizational resources but don't create differentiation. Healthcare, he said, has more big rocks than any industry he knows: electronic health record implementations, the ICD-10 conversion. Nobody thinks ICD-10 was a daily improvement, but everyone had to do it, and it didn't differentiate anyone.
Strategy is the third category, and the danger is that operational effectiveness and big rocks consume everything. Hunter cited the familiar 80/20 framing — 80% operational effectiveness, 20% strategy deployment — and the obligation it implies: the organization has to deliberately carve out time to gain deep insight into customer needs and meet them in a genuinely unique way.
The connective tissue across all three types of work is Plan-Do-Study-Adjust thinking. PDSA's beauty, in a healthcare organization, is that it is already common language. It is what caregivers use with patients every day; it is what units use to improve how they deliver care. Apply PDSA thinking to strategic planning at the executive level, and the executive team is speaking the same language as the frontline caregivers where value is actually created.
The system Hunter laid out applies PDSA thinking to strategy. Understand where you are today. Look at the gap between today and true north — where you want to be. Define the strategic issue. Make choices about how you think you can close it — real choices about what to focus on now versus what to defer. Recognize those choices as hypothetical solutions, because the future can't be predicted, and ask what must be true for the strategy to work. Identifying the most critical, most unknown assumptions is what actually starts the deployment process. Build out the solutions using lean learning loops, beginning with a Minimum Viable Product. Align and focus the work through catchball, because you are asking busy people to do something very different. And then manage the new ideas that inevitably arrive the next day, so learning becomes a continuous virtuous loop.
In the old way, Hunter said, the variables in the environment were treated as independent of each other, predictable, controllable, and stable. Systems thinking says the opposite — everything is interdependent, nothing is fully predictable or controllable, and the elements are highly dynamic. So a learning organization's view of its market position has to be current, comprehensive, and — most importantly — shared.
Hunter ran through a toolkit for building that view. Deep understanding of customers, using design thinking's convergence of desirability (what customers want), feasibility (whether you can produce it), and viability (whether you can produce it in a sustainable business model) — Webvan, again, failed at that nexus. This requires anthropological and ethnographic approaches to market research that supplement the traditional kind, and much of the relevant knowledge already sits at the front lines, where people know the customer's needs and pain points and can test solutions on real customers.
For understanding the organization itself, Hunter favors the Business Model Canvas — the right-hand side describing what makes the organization unique and generates revenue, the left-hand side describing what it takes and how it affects the cost structure, with the goal of the right side exceeding the left. The same canvas works for understanding competitors' business models. To get outside the transactional environment, Porter's Five Forces analysis looks at new entrants and the bargaining power of suppliers and customers. To look further out, PESTEL (or STEEPLE) analysis examines the broader environmental forces shaping the industry and the genuinely new business models emerging in it. The point of all of it: a perspective that is current, comprehensive, and shared.
With a clear view of the gap between today and true north, the organization defines its strategic issue. Hunter framed it in idealized-design, PDSA terms — look at where you are, where you want to be, get to the next target state, stabilize and standardize it so it becomes the new current state, then look again at where the ideal state has shifted and ask how to reach the next target. Progress is step by step.
One question recurs, especially in healthcare: to what degree does the strategic issue require innovation? Hunter credited Matthew May for the working definition — innovation is required when solving the strategic issue demands more than incremental thinking, when the organization doesn't really know the nature of the problem or opportunity and has to find its way there.
For generating and choosing solutions, Hunter drew on Roger Martin's work (and Matthew May's collaboration with Martin) and the integrated cascade of choices — five linked dimensions of a strategy. The strategy is a hypothesis: what winning looks like, where to play, where to win, how to win, and what capabilities and management systems are needed to create competitive advantage in the chosen space. The arrows run in both directions, because developing the hypothesis is iterative.
Hunter's example came from ThedaCare. The strategic issue was how to create a unique solution for a target audience. They chose to win with their sickest patients — people struggling to navigate a complex system of care, serious cardiac and cancer patients — and narrowed further, choosing breast cancer patients as a very narrow segment, on the logic that if they could win there, imagine what they could learn and spread to other audiences. The source of competitive advantage would be access, speed of diagnosis, and the customer's experience. The capability required was getting past being a transactional, volume-based organization to one with deep customer insight. The hypothetical solution had profound implications for the business model — so they had to ask what must be true: about customer reactions regardless of how much market research had been done, about how competitors would respond the moment ThedaCare moved, about their own ability to execute, and about whether they could rely on partners. The most critical uncertainty was whether they could get their independent physician partners to join the journey and create the kind of stickiness that would deliver real value to customers.
Once there is a hypothetical strategy and a clear sense of what must be true, the work moves to testing — the quickest, fastest, cheapest test of proof the organization can develop, the Minimum Viable Product. Hunter again drew on Matthew May's framing: what is the biggest worry, what do we need to learn, how can we test it, what would the measure prove. Run the experiment, study what you learned, and pivot or persevere.
Hunter named the payoff plainly. Thinking this way in strategy deployment means the organization stops arguing about who is right and starts learning what is right — by letting the customer tell it. Testing hypotheses is what makes an organization a learning organization rather than one run on power and on whoever can argue the loudest.
The planning function isn't finished once there are tested solutions. The proposed solutions still have to be aligned and focused with people who are already very different, and that is the work of catchball. Crediting friends at the Institute for Enterprise Excellence, Hunter distinguished two ways to do strategy deployment — the good one enables, coaches, and helps people; the bad one dumps work on people who already have operational effectiveness and big rocks on their plates. Catchball has two dimensions, one mechanical and one deeply human.
On the mechanical side, the strategy is an A3, a PDSA, with generated countermeasures that become the breakthrough initiatives. Hunter's preferred mechanical tool is the X matrix — while acknowledging that many people, himself included at first, react badly to it because it looks complex and daunting. He has stripped it to its chassis. In its most basic form, the X matrix asks: if I identify these priorities, which generate these initiatives, which consume these resources, will I hit the desired metrics? The logic can be reverse-engineered. The real value is that it lets the organization see the work.
Hunter's ThedaCare example showed why that matters. The information technology function had its own X matrix and its own business plan to radically redesign its work. When everyone poured their priorities into IT's X matrix, it generated 114 brand-new initiatives — not ongoing work, brand-new initiatives. IT people are good project planners and good at estimating resources, so they could say plainly: we can do this work if we get 60 more people and about $20 million more in consulting dollars. The organization couldn't do that. Through the dialogue process, it scaled back a number of initiatives and added some resources to IT. Everyone was probably still overburdened — but the tools reduced the overburden and increased focus.
The human side of catchball is the hard part. Catchball is all about dialogue, and healthcare organizations especially nurture professional autonomy, where many people hold veto power. Organizations aren't trained for this kind of dialogue and don't have systems for it. In the past, when there was plenty of demand and plenty of revenue, the stakes of poor alignment were low enough to live with — some things got done, some didn't, and it didn't seem to matter. When time and money are precious, it matters. Dialogic conversation starts with setting the frame: here is what I think we're trying to do and why it matters, here is the support you can expect, here are the constraints you'll operate under. Then people get to express their perspective and advocate for what they believe, and then the leader gets to ask questions back. That circular process builds the muscle of coaching — coaching for improvement and for development. Catchball works best, in Hunter's experience, with A3 thinking as the communication tool, visual management so the work is visible, project management thinking to estimate and sequence resources, and genuine skill in the practice of effective dialogue.
Once the organization has decided what to do, the next thing that happens is that new ideas fall from the sky — and Hunter was clear that the organization wants new ideas. The question is how to manage that inbound work while maintaining focus and accelerating learning.
It starts, again, with seeing the work already in progress and the resources devoted to it — a rudimentary X matrix serving as a visual management tool. As new ideas arrive, the organization asks what gap the idea closes and why that gap matters now. It needs an evaluation process — but not the old 16-page business planning form, because people generally don't have enough information at that stage and many ideas still need to be explored. Hunter's tool is a proposal A3, PDSA thinking again: what gap are we trying to close, why does the gap exist, what do we think will close it, what experiments might we run, what resources would those experiments need, what benefit do we expect.
Because the organization may not have capacity to act on every good idea, Hunter described a "wait-work board" — terminology borrowed from industry. The wait side holds ideas that are promising but need a couple more inputs freed up. The work side holds ideas with everything they need, waiting only for capacity before entering the working process. An impact-difficulty matrix helps pick off the ideas with the most promise. The principle: get all the ideas on the table, visible, managed with transparency — rather than managed through back-room conversations and the old power politics of grabbing the resources you need.
With that visual system in place and work in process, the organization studies it with the basic PDSA questions — what did we expect, what actually happened, what did we learn, what will we try next, what barriers can we remove. Those questions, Hunter noted, work at the most basic form of improvement and scale all the way up to strategy formulation and deployment. They take the emotion out of the process and get everyone thinking positively about what can be accomplished.
The questions after the talk pressed on the harder edges of Hunter's argument.
Asked how a hospital built on providing all care to all people can be truly differentiated, Hunter empathized — ThedaCare was one of those organizations. Part of the answer is distinguishing where you must win right now from where you play to play; complex organizations have indicators where maintaining current performance is fine and others where a real breakthrough is needed. And part of the answer is harder: ThedaCare did face difficult choices about specific services. It got out of inpatient pediatrics — but not by simply abandoning the service. It partnered with a children's hospital to do it.
Asked whether the language of "winning" makes some hospitals uncomfortable — implying losers in the market — Hunter said he finds that discomfort, but not where he would expect it. He has done workshops with nationalized healthcare systems, in Canada and in South Africa's public system, and those organizations took right to the idea, because the point isn't beating a competitor. The point is being so unique that customers and payers genuinely value you. If you win with customers, competitors have to figure out their own response. Hunter's stance: I'm not trying to beat a competitor, I'm trying to win with customers.
Mark Graban pushed on multi-site systems, describing a health system with five roughly equal hospitals where Hospital A is stacked up in its emergency department while Hospital B, 20 minutes away, has open beds — and asked at what point the system steers or transfers medically capable patients. The answer Graban had heard in real life was that Hospital A doesn't want to lose the revenue, which, Graban said, is not really a system. Hunter agreed it depends on the incentives, and noted that the term "system" often gets applied to what is really a conglomerate of enterprises. The larger systems in the country, he said, are moving from a holding-company model to an operating-company model precisely because they've decided real competitiveness means delivering better value at the bedside and taking the back-office waste out.
On how to decide what true north is — and whether hospitals share the same strategy because true north tends to be the same — Hunter pointed to the ThedaCare board's discussion of what it called "owners' expectations." The board members saw themselves as representing the community, and it was the community that owned ThedaCare. Those owners' metrics were different from operational metrics, and notably, financial performance was the fourth of four. He described another healthcare organization he was working with that was pushing past the standard safety-quality-satisfaction-engagement metrics entirely, asking what it would take to be genuinely relevant and meaningful as a not-for-profit in its community, and defining true north from that — prompted by the recognition that being different requires asking what would be different and how the organization would know if it was.
Hunter's session is a strategy talk, and the system he described is a way of thinking, not a piece of software. But several of its core mechanics are visibility and tracking problems, and that is where infrastructure connects.
The strategic management system runs on seeing the work. Hunter said it directly and repeatedly: the X matrix's real value is that it lets the organization see the work; the wait-work board exists to get all the ideas on the table where they can be managed with transparency rather than through back-room politics; managing the flow of new ideas starts with seeing the work already in progress and the resources committed to it. A learning organization's view of its position has to be current, comprehensive, and shared. "Shared" is the operative word. A strategy A3 on one executive's wall, an X matrix in one planning binder, a wait-work board in one room — none of those is shared across a complex multi-site organization. Infrastructure that holds the breakthrough initiatives, the supporting improvement work, and the proposal A3s in one place, visible to everyone who needs to see them, is what makes "shared" real at the scale of a health system.
Hunter's insistence on connecting executive strategy work to frontline improvement points the same direction. His argument for PDSA as common language is that it lets the executive team connect with the caregivers where value is created. That connection only happens operationally if the strategic initiatives and the daily improvement work live in the same system, in the same language, so a frontline team can see how its work ladders up to a breakthrough initiative and a leader can see whether strategic intent is reaching the front line. The 80/20 split between operational effectiveness and strategy is easier to honor when both kinds of work are visible in one place and the strategic 20% doesn't quietly get crowded out by operational work nobody is tracking against strategy.
The catchball problem is partly a visibility problem too. The ThedaCare IT example worked because the X matrix made it possible to see that 114 brand-new initiatives were being poured onto one function — overburden that would otherwise have stayed invisible until it failed. Catchball as genuine dialogue, rather than dumping, depends on both sides being able to see the real load: the operational effectiveness work, the big rocks, and the new strategic initiatives all at once. Infrastructure that surfaces the full demand on a team or a function gives the catchball conversation honest data to work from.
And Hunter's whole reframe — from arguing about who is right to learning what is right — depends on running experiments and studying what they teach. MVPs, learning loops, the PDSA study questions: those produce learning only if the experiments and their results are captured somewhere durable rather than living in memory and meeting notes. Infrastructure that records what was tried, what was expected, what happened, and what was learned is what lets a learning organization actually accumulate learning instead of re-litigating the same debates.
None of this changes the substance of Hunter's argument. Strategy is still about making choices. Planning is still a learning exercise under uncertainty. Catchball is still a human discipline of dialogue and coaching that no tool can perform. What infrastructure does is hold the system together at scale — make the work visible and shared, connect strategic initiatives to frontline improvement, give catchball honest data about real workload, and capture the learning so the organization compounds it. Hunter described a system; a system needs somewhere to live.
What does Jeff Hunter mean by "putting strategy back in strategy deployment"? He argues that when hoshin kanri was translated into English — first as "policy deployment," then "strategy deployment" — organizations lost the essence of strategy itself. Strategy is fundamentally about making choices: choices about what will make the organization genuinely unique in ways that matter to customers. Many organizations deploy plans without making those real choices, so what they're deploying isn't really strategy. Putting the strategy back means reframing deployment as a continuous learning system built on choice-making, experimentation, and customer insight rather than a fixed plan or a periodic event.
Why does traditional strategy deployment lead to overload and "sameness"? Because organizations fail to make deliberate choices. When every priority is labeled strategic, teams become overburdened and focus erodes. And strategic plans across an industry start to look identical — improve safety, quality, satisfaction, engagement, financial performance, and grow, all at once. When every organization pursues the same strategy, the industry becomes a commodity market competing on price. Real strategy requires choosing what to focus on now, what to defer, and how the organization will be meaningfully different.
How is strategy different from operational improvement and "big projects"? Hunter described three types of work. Operational effectiveness is improving the process by which people do their existing jobs — taking a current standard and making it better. "Big rocks" are large projects that consume cross-organizational resources but don't create differentiation (he cited EHR implementations and ICD-10 conversion — necessary, but not differentiating). Strategy is the deliberate work of gaining deep customer insight and meeting customer needs in a genuinely unique way. The risk is that operational effectiveness and big rocks consume all the available time, leaving no room for the strategic 20%.
What is the "old mental model" Hunter critiques? The belief that an organization can predict and predetermine the future and command and control both itself and its environment. In that model, the organization works like a biological body — a central brain thinks up the answers and communicates them through the nervous system, and everyone executes as predicted. It casts the leader as the problem-solver and makes planning an event done every few years. Hunter was candid that this was the model he ran himself for years, including a management-by-objectives program, and that its tools no longer work against modern competitors.
Why is strategy a "hypothesis"? Because planning happens under conditions of uncertainty and competition, and systems thinking tells us that the moment an organization acts, it has changed the game. There is no perfect information, and no organization can fully control itself or its environment. So a strategy is the organization's best current hypothesis about how it will create differentiation — something to be tested and learned from, not predicted with certainty. This makes strategic planning a learning exercise rather than a forecasting exercise.
What is a "learning organization" in this context? Not an organization full of people who enjoy learning. A learning organization is one that is genuinely good at learning what is creating value and what isn't, and at building the knowledge management systems to capture that learning. Hunter noted that this learning capability, done well, becomes a form of competitive advantage in itself.
What's the lesson of the Webvan story? Webvan, an early online grocery delivery company, was well capitalized and spent heavily on market research to size and segment the market, then built hundreds of thousands of square feet of warehouse space and a fleet of vans — and went bankrupt within months because it oversized the solution. The contrast Hunter drew: rather than predicting demand and building ahead of it, start from deep customer insight, form hypothetical solutions, and test them with a Minimum Viable Product, building out through learning loops. His rural-hospital van story is the same lesson at small scale, where asking "what must be true?" and running a cheap test avoided seven months of planning and an unnecessary $100,000 build.
What is a Minimum Viable Product in strategy work? The quickest, fastest, cheapest test of proof an organization can develop to test a critical assumption behind a strategic hypothesis. Instead of committing major resources based on prediction, the organization identifies what must be true for the strategy to work, isolates the most critical unknown assumption, and designs a small, low-cost experiment to test it. Hunter's framing questions, drawn from Matthew May: what is the biggest worry, what do we need to learn, how can we test it, what would the measure prove. The MVP lowers risk and accelerates insight, and lets the organization pivot or persevere based on real evidence.
How does Plan-Do-Study-Adjust thinking apply to strategy? PDSA is the common thread across operational effectiveness, big rocks, and strategy. In a healthcare organization it is already shared language — caregivers use it with patients, units use it to improve care delivery. Applied to executive strategy work, it gives leadership the same language as frontline caregivers where value is created. The strategic management system is PDSA applied: understand where you are, define the gap to true north, make choices, identify what must be true, test with MVPs, align through catchball, and study the results to decide what to try next.
What is the "integrated cascade of choices"? A strategy framework Hunter drew from Roger Martin's work — five linked dimensions treated as a hypothesis: what winning looks like, where to play, where to win, how to win, and what capabilities and management systems are needed to create competitive advantage. The dimensions connect with arrows running in both directions because developing the strategy is iterative, not linear. Hunter's ThedaCare example: choosing to win with the sickest patients, narrowing to breast cancer patients as a test segment, with access and speed of diagnosis as the source of advantage.
What is catchball, and what makes it hard? Catchball is the back-and-forth dialogue that aligns and focuses strategic work with the people who have to do it. It has a mechanical dimension — using tools like the X matrix to see priorities, initiatives, resources, and target metrics — and a human dimension, which is the hard part. The human side is genuine dialogue: setting the frame (what we're trying to do, why it matters, what support and constraints apply), letting people express and advocate for their perspective, and asking questions back. Healthcare organizations nurture professional autonomy and aren't trained or equipped for this kind of dialogue, which is why catchball is difficult — but it's how overburden gets surfaced and reduced.
What is the X matrix, and why do people react badly to it? The X matrix is a visual catchball tool that connects priorities, the initiatives they generate, the resources those initiatives consume, and the metrics desired — so the logic can be reverse-engineered and the work can be seen. Many people (Hunter included, at first) find it complex and daunting, which is why he strips it to its basic "chassis." Its real value is visibility: in his ThedaCare example, the IT function's X matrix revealed that everyone's priorities were generating 114 brand-new initiatives, which let the organization scale back initiatives and add resources rather than silently overburdening the function.
What is a "wait-work board"? A visual management tool for handling the flow of new ideas. New ideas are evaluated with a proposal A3 (what gap, why it exists, what might close it, what experiments, what resources, what benefit). Ideas that are promising but need more inputs freed up sit on the "wait" side; ideas that have everything they need and are only waiting for capacity sit on the "work" side. An impact-difficulty matrix helps select the most promising. The point is to get all ideas visible and managed with transparency, rather than through back-room conversations and resource politics.
Can every hospital "win," or does winning imply losers? Hunter said the discomfort with "winning" exists but not where he expects it. He has run workshops with nationalized healthcare systems in Canada and South Africa, and those organizations took readily to the idea — because winning, in his framing, isn't about beating a competitor. It's about being so genuinely unique that customers and payers value you and want you to succeed. If an organization wins with customers, competitors have to work out their own response. Hunter's stance: don't try to beat a competitor, try to win with customers.
How should an organization decide what its true north is? Hunter cautioned against defaulting to the standard metrics (safety, quality, satisfaction, engagement, financial performance) that make every organization's plan look alike. At ThedaCare, the board defined "owners' expectations" — the board members saw themselves as representing the community that owned the organization, and those metrics differed from operational metrics, with financial performance ranked fourth of four. He described another organization defining true north by asking what it would take to be genuinely relevant and meaningful as a not-for-profit in its community — driven by the recognition that being different first requires asking what "different" would even look like.
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