NHS Change:

Analysis of Nurse-Led practice setting strategy

The 2002 merger between three hospital institutions in the United Kingdom, to form the King Edward Hospitals, National Health Systems (NHS) Trust was responsive to increased pressures on Britain’s healthcare system to meet new mandates for allocations. In Barsoux and Gilmartin (2007) Leading Hospital Change: Improving Hospital Performance, the case study of the efforts of Executive Director of Nursing, Tracey Burns in her leadership of the new organisation in redirecting strategic performance of the admission-to-discharge chain prompted a series of change management initiatives and opened debate on the scope of current protocol for hospital institutions, and specifically Nurse-Led administration within NHS.

The foregoing analysis reviews the case study, and looks to contemporary organizational leadership behavior models from the perspective of J.P. Kotter’s (2002) Transformation Management theory. Consecutive to the evolution of the NHS case study, is the emergence of change management solutions in the interface of human and artificial intelligence in the last decade; where knowledge-based collaboration through healthcare management information systems (HMIS) now serves as a core point perspective like that of the Trust’s ‘reinvestment’ strategy implemented by nurse executives for reduction of admission-to-release inefficiencies.

Operational inefficiencies are the number one culprit in hospital fiscal waste. The case study outlines the shift in NHS policies prompted by the UK Parliament in the Labour Government NHS reforms in 2002. Issues of fiscal waste clearly reflect systemic inadequacies and where competence is in question, leading to allocations restrictions institutions and even investigations. The King Edward Hospitals NHS Trust offered participating institutions a chance at reconfiguration of current systems with forward thinking approaches to long standing problems.

SECTION a: Case Study & Kotter’s 8 Steps

The case study opens with a history of King Edward Hospital NHS Trust merger, and discussion of change management challenges presented to Executive Director of Nursing, Tracey Burns on behalf of consortium under her supervision for assessment and feasibility of reduction of patient admissions retention. Actions items to the preliminary strategy included study of patient admission and retention within the Trust’s institutions. Initial review of procedures to patient discharge revealed that patients were subject to extended admission due to waits on tests or other outpatient treatments. Other issues pertaining to records and referrals to Social Services and other third party interveners added to the inexpedient process. Patient journey management were so ineffective it was determined, that institutional over capacity was at an all time high.

Theoretical consideration to the case study employs Kotter’s popular ‘8-Step’ Transformation Model for organizational change. Concurrent to other organizational theories where the breadth of interest engages both the leadership strategies and mechanistic logics of institutional change management practices mentioned in Hiatt’s employee based, ADKAR, Bertalanffy’s systems theory, and Burke’s transformation leadership models, Kotter’s transformation thought offers perhaps the most apt interpretive framework for constructive, explanatory insight into the King Edward Hospital NHS Trust and its potential as a national healthcare consortium to truly serve patients according to professional best practices.

If benchmarking conclusively states the level of participatory adherence to national recommendations to institutional risk management and its impact on both finance and patient care, then the process by which improve is achieved may be narrowed to the efficacy of an institution’s logic model. Behind those abstract transformations, however, is real professional expertise and well intentioned thought. The capacity building strategy deployed by the executive management in nursing at the Trust is an almost seamless facilitation of Kotter’s transformation thought. Grounded in iterative decision making, the following outlines the theory to practice evidenced in the step-by-step response by Burns’ and her colleagues.

Transformation management is the culmination of team-based, reflexive practice in change management. In Strategy for Change Management, Kotter adopts an 8-step process for risk management planning. Guidelines to the transformation model are illustrated in Table 1.

The ‘8-Step’ Strategy or Change Management

1. Establish a Sense of Urgency — Examine market forces facing the organization and the impact of these forces. Identify and discuss the impending crises.

2. Create a Guiding Coalition — Establish a team of leaders that are credible, have authority and expertise in the area of focus.

3. Develop a Vision and Strategy — Establish the target vision and strategies.

4. Communicate the Change Vision — Develop a communication plan to present and re-enforce the change vision.

5. Empower Broad-based Action — Identify and remove barriers to change.

6. Generate Short-Term Wins — Plan milestone achievements.

7. Consolidate Gains and Produce More Change — Build on past successes so that change becomes permeated throughout the organization.

8. Anchor New Approaches in the Culture — This must be done after the prior 7 steps are completed (Kotter’s study, as cited in Leading Change, 2007).

Table 1. Kotter’s ‘8-Step’ process Transformation Model (Kotter, 2007).

Prelude to the case study with the King Edward Hospital NHS Trust merger opens with Kotter’s key identifier of the instigative force behind the acknowledgement that for many transformation organizations change is inevitable, and this is: 1) established with a sense of urgency, which led to the formation of the Trust’s collaborative efforts amidst widespread retractions of institutional allocations. The embodiment of the Trust as evidence of: 2) creation of a guiding coalition was established through the professional credibility, authority and expertise of the Board of Directors; and 3) enacted by way of institutional policy and the directive of committees led by key staff like Tracey Burns, in support of the Trust’s larger vision and sustainable strategy. Burns was brought on board to steward the admissions-to-release project within the institution’s reinvestment strategy plan, as a voice for: 4) communicating the change vision to a consortium of stakeholders, including nursing staff and partner hospital administration within the trust toward development of a viable transformation. To this end, Burn’s fulfills Kotter’s theoretical proposition, in her capacity to delegate authority to peers, thus: 5) empowering broad-based action and inciting those actors to assist in the identification and removal of barriers to change.

Short-term wins within Burn’s strategy served as a foundation to: 6) milestones for change in the design of a training and database sharing network where integrated information could serve as a: 7) long-term consolidation of gains to produce more change. Rectification of inefficiencies in patient care during the hospital journey demonstrated outcomes consistent with the impetus of Burn’s original strategy. While not all goals were attained without obstacles, the reduction of fiscal waste is a signal that the Nurse-Led project had positive impact, and may serve as a replicable model for evidence-based practice in forthcoming Trust rehabilitation initiatives, and externally at other NHS institutions in the UK.

Review of what healthcare institutions are doing from a fiscal perspective is critical in that risk prevention is a ‘total’ change management concept, and one obviously not listened to at times with exception of the cost to national healthcare and to institutions where competitive capitalization is taking place (i.e. research). Review of the complications faced by Tracey Burns and the King Edwards Hospitals NHS Trust, and underscores the global transformations taking place between policy and patient. Impetus to better systems of business intelligence and specialist intervention, knowledge management as a strategy within this transformation offers much for healthcare institutions and their leaders; connectivity in management of practice and patient care.

Evaluation of the hospitals soon into the organizational assessment revealed that the inefficiencies were leading to three (3) iterative problem areas verging on crisis: 1 poor communications; 2) increased incidence of hospital associated infections leading to longer admission beyond original diagnosis or intervention; and 3) overcrowding to the point of backlog. Discussed more extensively in Section B, the framework developed out of the organizational assessment was loosely based on the three issue areas. Poor communication was the subject of internal stop-gaps, where patients were being held for testing or results. External communications issues were lengthening time of patient journey in response to waitlists to social services and other aftercare admission in other healthcare institutions. The remainder of the case study is dedicated to the development of the Trust’s Nurse-Led change management strategies and the process by which decisions and partial implementation was achieved.

The Kotter Transformation Model is most applicable to organizational initiatives emphasizing long-term change. Highly compatible to systems theory, where organizations of scale increase capacity for longitudinal assessment and results, Kotter’s transformation model presents the most comprehensive leadership-centric approach. Where leaders are responsible for different nodes in the operating system of an organizational system or knowledge database, the recommended process employs the most thorough engagement in expert change management planning. Successful systems change processes are typically subject to meticulous oversight, and are the subject of new or re-articulated decisions within the management chain and may be momentary to long-term.

Liability to malpractice was of course an important consideration to the appointment of CEN, Burns to the reinvestment strategy. The range of detriments posed to staff and hospital institutions, while discussed briefly, certainly set the format for decision making at the executive management level. Accountability to issues of liability are perhaps the most persistent factor mitigating change, regardless of integral to flexible transformations. The variability in problems faced by the King Edward Hospital NHS Trust during the period in question, instigated a multi-level response in knowledge sharing and inclusion on practice. Kotter’s theory relies upon such a method, where strategies are an exercise multi-tiered obligation.

As Kotter points out, the transformation model may not be suitable for organizations that are in pursuit of prompt change, and the series of responsibilities which result from consortium relationships may apply to one or all organizations within the scope of his definition of institutional cultures: 1) Developing Social Construct; 2) Oriented Social Construct; 3) and Pluralistic Social Construct types. Evidence-based practice in healthcare is compatible with Kotter’s proposition. Process methodology including the ‘8-Steps’ process in three (3) phases — 1) Creating Climate for Change, 2) Engaging and Enabling the Organisation, and 3) Implementing and Sustaining the Change — is illustrated in Figure 1.

Figure 1

Figure 1: The model follows a 3-phase, 8-step process.

Since knowledge sharing has come to the fore of change management practices in the NHS and its healthcare institutions in the last decade, British hospitals have benefited greatly from the advancement in record keeping, and informatics management optimized through integrated networks of partnership and practice. A leader in the global trend of transforming human service organizations into learning organizations, the UK NHS has been a leader in knowledge management strategies from inception of ICT systems integration in healthcare, and supports the investment in knowledge sharing networks as a vehicle for promoting a multi-level organizational approach to management of tacit and explicit knowledge as illustrated in Figure 2.

Figure 2

Figure 2: Knowledge Sharing Between Individuals in Organizations (Austin 2008).

As standards in nurse-patient synergy are expanded to include healthcare informatics and new it systems, healthcare institutions in the UK are better equipped to meet QA measures (Department of Health, UK, 2010). Systems of integrated knowledge increase collaboration amongst nurses and medical professionals through the exchange of operating policies, patient procedures, and chain management practices. The nature, mediation and plan of implementation of knowledge is as important as the goal and objectives for which it is employed. While ‘change’ is considered a ‘good’ from an organizational theory perspective, without systems integration and a method of application to realize outcomes, liability exceeds benefit and with those risks the potential of exponential increase of administrative challenges beyond the prospectus of preliminary strategy.

SECTION B: CRITICAL ANALYSIS

As a Physician of Obstetrics and Gynecology in a tertiary healthcare institution, Tawam Hospital in the United Arab Emirates (UAE), I am well versed in the type of administrative and process related conundrum presented in the case study on King Edward Hospital NHS Trust in the UK. Indeed, parallel patient retention and ward administration issues mentioned in the assessment of the Trust’s former admission-to-discharge chain are common issues wherever the most cutting-edge responses to patient systems management have not been made effective in policy and administrative procedure.

When knowledge sharing networks first appeared on the scene of international medicine over a decade ago, the formation of a universal framework to best practices protocols and competencies in healthcare administration was generative to an entire dialogue dedicated to the reform of hospital institutions; where a common set of doctrines might inform practice setting systems. Replicable feasibility studies like those addressed in the NHS Trust case study are the outgrowth of this movement toward sustainable institutions. Change management theorists offer a continuum in feasibility assessment methods for lead institution evaluation, and particularly Questionnaire methods dating back to Harrison (1972) to Goffee and Jones’ (2000) organizational culture analysis.

Harrison’s Questionnaire based on four organisational ideologies: 1) power; 2) role; 3) task; and 4) person using a common set of doctrines, myths and symbols is made relevant in my experience at Tawam Hospital where I observe determination of staff orientation toward systems administration and leadership within a matrix of interpretations that may only be discerned in finite form through criterion of a point-by-point survey instrument. The modular tool designed by Goffee and Jones is particularly popular, and offers a flexible or ‘deconstructive’ method of developing an aggregate data set that is also conducive to back end queries enabled by way of insertion of responses to the model’s five key drivers: Vision & Strategy; 2) Leadership; 3) Processes; 4) Culture and; 5) Physical Work Environment into a statistical database for dissemination of new information by way of it based abductive logic.

From ethical dilemmas in urgent care to constraints due to nursing shortages and communications lapses with partner institutions, the number of problematic occurrences in a single day at Tawam Hospital poses the kind of matrix organization mentioned in Goffee and Jones, where the ideological factors conceived in Harrison are further advanced through the current sustainable model of healthcare institution oversight. The centrality of patient rights and responsibilities in the current era augments our thoughts about the externalities to decision making in discovery of inefficiencies in the institutional management of the single patient journey, such as the influence of national legal culture in the prioritization of information and its use value in strategic solutions. For instance, the ‘point prevalence’ management of patient journeys supports nurse led decision advocacy in the restatement of hospital policy. Popularity in the ‘hands back’ approach to traditional vertical decision making by medical practitioners ensures better adherence to protocols that imply institutional liability.

Complications to the admission-to-release equation in the case study, for example, were fostered by the high incidence of healthcare acquired infections (HAI). The prevalence of HAI in prolonging patient retention is a serious inhibitor to streamlined patient journey planning, and as seen in the discussion of the UK NHS Trust, the sheer exacerbation of patient numbers exceeding capacity. Separation of healthcare policy is not always the answer either, where the impact of HAI secondary infections usurp allocations within the total chain of fiscal control. In the UK, this has led to approximately £1 billion in government allocated funds are required to stop HAI in the country annually, with upwards to 5000 deaths per year attributed to poor aseptic care of patients (Aziz 2009).

Hospitals often face the kind of cyclical problem reflected in the management of HAI, in the sense that a series of pertinent patient related issues form a web of risk while admitted, that is then difficult to untangle through traditional physician management. Where executive nursing staff are called forth to cease crises in institutional management, inefficiencies at times reach levels of exponential acceleration; a virtual traffic jam were incremental response and prolonged time to end solution might even exceed time lapses involved in the initial problem. Regardless of complication, however, the use of horizontal support management teams has proven to more, not less, effective in regaining systemic control where vertical administration is now more likely to be destabilized due to the expansion of patient populations, treatments, records and referrals to outside services.

At Tawam Hospital, partnership institutions are critical to channel operations, and endorsement by large institutions through agreements and networked activities points to the importance of the external picture in relation to the transformations taking place in tertiary institutions. Evidence-based knowledge sharing is a salient dynamic to the maintenance of the Hospital, and its capacity building strategy as a growing healthcare institution. Like the Trust, Tawam is undergoing ‘co-optation’ of sorts in the area of ICT healthcare systems architecture as a conduit to practice. The development of an information systems approach is extraordinarily important to our ability to work in conjunction with ward divisions, and in participation in our national and international network. Despite the upfront costs of planning of new it HMIS systems, institutions have been able to markedly decrease time lapse in service provision, and increase precision in delivery. This includes the viability of informatics through “patient-centric management systems,” and the possibilities afforded to those committed to betterment of those circumstances through implementation of HMIS as a substantive aspect of nurse-patient synergy in the practice setting (Tan and Payton 2010).

Like the hospital group involved in the NHS Trust, the networked partnerships include clinical treatment and social services providers already connected through the national knowledge sharing network; and would ostensibly incorporate internal records regarding patient journey and schedule since admission with continuity in referral and patient education. Informed by researched findings from the existing hospital led research studies, forthcoming changes derive meaning in relation to benchmarking practices in discharge procedure, and serve as a feedback loop for outcomes to the process. The interest in replicable feasibility assessments is also supported at Tawam, and the institution involves ‘transfer initiative’ methodologies where valid to control of risk to finance and patients.

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