Problem
King Edgar NHS Hospitals Trust is contending with problems of financial deficit running into millions of dollars, the waiting list, congestions at the admissions ward, delayed discharges, and patient complaints. These problems have caught the attention of the media which has, in turn, relayed the situation to the public and the government.
With the new national health council reform to reduce the waiting list to 3 months by 2008 and the awarding of stars to hospitals that perform well, before 2003, the King Edgar NHS Hospital was awarded one star which indicated that it was not performing well in its expected targets. With the King Edgar NHS Hospitals’ trust being cash-strapped, the trust board needs to come up with a solution to the problem if they are to meet their targets and those of the national health council. Finding a solution guarantees they receive full funding which they will be able to spend in addition to other associated advantages.
Macro & Micro Level, Internal & External Factors
Lack of enough resources in terms of finances, staffing and hospital equipment, wards and hospital policies are some of the internal factors that are facing the King Edgar NHS Hospitals’ trust. Lack of resources ties the hands of the board since it cannot be able to employ any more staff to help in the Accidents and emergency area, nor can they expand the hospital to allow more bed space for the waiting patients. With the restricted number of staff, working not only in the admission and discharge but also in the wards and the theater, they can only admit and discharge a limited number of patients at a given time (Olson 2001).
Similarly, shortages in hospital equipment and beds mean that even after admission, the patient has to wait till there is a bed available for them. Considering that the hospital policies expect only the specialist physicians to make final decisions about discharge of patients. With the number of physicians decreasing while that of the patients in need of discharge increasing the hospital ends up hosting many patients who are in good health occupying beds because they have no one to discharge them. The case of March 2003 recorded the hospital having as many as 30% of the hospital being medically fit.
According to Flash, Froehlich, Helgeson & Jensen (n.d.) the external factors include political influence, partners such as the social services, the media, and economic factors. Partners including the social services are responsible for the discharge of patients that have no family to take care of them. Their services are slow and thus increase the bed occupancy with patients that are stable medically. The tight regulations that the government has enforced through the national health services and strategic health authorities put pressure on the hospital to constantly perform. This pressure may lead to the misreporting by drafting extra physicians, nurses, and radiographers to explain how the hospital meets its targets. Health figures also showed that these targets might distort clinical priorities, where patients are sent home early just to have them rushed back to the hospital.
TOWS Analysis
It is a method of comparing external opportunities with internal strengths and internal weaknesses on one level while comparing external threats with internal strengths and internal weaknesses on the other level. The comparisons are conducted in the process of developing a strategy that pits internal against external forces.
Emphasis is placed on the Weaknesses and Threats (WT), Weaknesses and Opportunities (WO), Strengths and Threats (ST) and Strengths and Opportunities (SO) (Mankins & Steele 2005, p. 64).
Weaknesses and Threats (WT)
Since any organization with great weaknesses needs to resort to having a survival strategy, King Edgar NHS Hospitals’ trust having known their problem upon the admission of none acute patients should consider liaising with other hospitals. Although the arrangement may be a little far to take care of the non-acute patients that visit Edger NHS, it would allow the hospital to work on the acute patients only. The media is one of the external threats that the hospital has to deal with. Additionally, the hospital should be able to inform the media on the steps being taken to improve the situation at the hospital (Amabile & Khaire 2008, p. 100).
Weaknesses and Opportunities (WO)
One of the great weaknesses of the hospital is poor communication from one section to another the Burns team could in the process come up with measures to ensure that communication from one section to another runs as smoothly and is on time. Poor communication with the family members of the patients and the social services is also a weakness that increases waiting time. The hospital should come up with a team or improve the communication team already there to have the contact of the responsible family members for their patients. The communication team will also inform the social services and family early in advance so that they can be ready to take the patients immediately after discharge.
Another weakness of the hospital is its few staff. with hospitals having to serve as large areas, the hospital could use these statistics as means to lobby for more funds from the donor and the government.The nurses also have an opportunity here to take over duties from the specialized physicians.These duties e.g. patient discharges of cases that are not very complicated could go a long way in reducing the waiting time at the hospital.
Similarly, Brass noted that the shortage of specialized physicians in King Edgar NHS Hospitals’ trust opens an opportunity for other medical professionals as nurses to engage in areas like the discharge of patients which would aid in reducing the time in waiting for the hospital (Fleisher & Bensoussan 2007)
Strengths and Threats (ST)
One of the great threats to the hospital is the media whose coverage puts the credibility of the hospital to question. With a strong team like Burns, the media can get involved in helping to market the hospital. The team should ensure that the efforts the hospital is making are also known to the media and factors that hinder the hospital from reducing the waiting time like the shortage of finances are well known to the media. This can help the hospital get funding from well-wishers after the media covers these factors and enable the hospital to get the assistance needed (Swayne, Duncan& Ginter 2006).
Another threat to the hospital is the National Health Services regulations. Burns team organizes workshops and presentations to many hospital committees. They could take the opportunity to also invite stakeholders from the national health services and the social to the workshops.This would communicate to them that the hospital is making efforts to reach the set target. Hence they can bargain with the national health services to have more time for their effort to produce tangible results as well as encourage the social services to improve on the time they take to have their patients from the hospital (Goleman 1998).
Strengths and Opportunities (SO)
Here the organization builds on their strengths to take advantage of the opportunities around them. The hospital has well-qualified nurses and matrons that could take over duties like the discharge of patients.This could go a long way in reducing the waiting time at the hospital.
The hospital serves large areas. With it having to take both acute and none acute cases, the hospital could use these as leverage to bargain for extra funds from well-wishers and government. These funds can be channeled to employing more staff thus reducing the waiting time at the hospital Mankins & Steele 2005, p. 72).
With leaders like Burns and Green, the hospital could improve its relationship with other partners like the social services and other hospitals. This will enable them to work together to reduce the waiting time. The other hospitals by taking care of the non-acute patients from the hospital and the social services by reducing the time the patient spends in the hospital after discharge.
Figure 1 – TWOS analysis template.
Kotter’s Analysis
Establish a sense of urgency
In this first part of the analysis, the relevant stakeholders identify and discuss the crisis at hand, potential crisis or major opportunities. In this case the crisis is triggered by the media and the national health council. With the exposure by the media of the patient waiting problem in the hospital and the regulations of the national health council, the trust board is prompted to act to prevent withdrawal of funds and bad publicity. The board’s chairman Roger sets up a trust board meeting where the crisis is addressed and its urgency passed to the members (Coutts)
Form a Powerful Guiding Coalition
Secondly, the organization works towards putting up a group that can cooperate to lead the desired changes. The board appoints Burns who has been an employee at the hospital for a long time and is familiar with both the managerial tasks as well as the medical skills. Burns is in an executive position and her authority is of great advantage at this point of the exercise. Burns also has the right attitude for the job. She sees an opportunity in the assignment given and is not hesitant to take it up. Most importantly, Burns believes that there is a solution to the problem. She therefore teams up with Green who had conducted research within the hospital and believes in the success of the strategy suggested by Burns. This team assisted by Edwards formed a guiding coalition for the admission-to-discharge chain (Hagell III, Brown & Davison 2008, p. 81)
Create a Vision
A vision sparks motivation and helps keep all the projects and changes aligned. At this stage a vision developed must direct the necessary change. Strategies instrumental in achieving the set strategy should be enacted by the team, as well as use any available avenue or channel in transmitting the vision to the hospital as a unit. Burns’s vision is to improve the admission-to-discharge chain by introducing nurse-led discharges. She shares this vision with those she sees as key in making the strategy result in the desired change (Coutts; Flash et.al)
Channel the mission to the organization
According to Kottler (1996), the demand for the mission is considered to have an effect of ten times the number waiting for it to be communicated. Coutts emphasizes that leaders must be seen “walking the talk.” For people to view the effort as vital and necessary, “words” and “deeds” are instrumental in communicating the new ways.
First, Burns should establish a workshop for the matron who would be the leader if the nurses–led discharge were to succeed. She invites green and together they show the matrons why and how the nurses could take up the medical responsibilities and how they would impact the admission-to-discharge chain. Burns also makes presentations to the senior medical staff committees and the medical directorate so that they can sign off on the ideas from her workshop (Swayne et al. 2006).
Delegate the vision to others for action
Due to the presence of unexpected obstacles, the team should task the action on the vision while they embark on mitigation of the obstacles. Coutts explains this stage as involving activities such as changing the organization so as to put people where they are required, freeing up key people from existing responsibilities so that they can concentrate on the new effort, implementing changes in specific areas of participation, and mobilizing funds to assist in the implementations.
One of how Burns and her team achieve this goal is ensuring that the matrons are relieved from their bed management duties to free allow their involvement in the discharges. However, this was met with challenges since other areas required the equal attention of the matrons. The team was also able to work with the social services in legislation to get funding to help them avoid delaying patients in their care who have been discharged by the hospital (Coutts n.d., & Flash et al. n.d.)
Create short-term wins after careful planning
In order for the team to motivate the participants, the team expects the visible performance of wins although real transformation might take a relatively long time to achieve. Consequently, this is the stage where utmost care should be taken by the team leader while acknowledging and honoring the participants who contributed to the wins. Burns and her team had a few wins by mid-October 2003. Progress was seen in the reduction of the monthly point prevalence assessments in two of the three hospitals. The percentage of patients with estimated date of departure had risen from 10% to 90% in those few weeks. Improvements in the lounge usage were also reported as well as progress in pilot studies related to the strategy (Amabile & Khaire 2008, p. 106).
Merge improvements and maintain the change velocity
According to Kottler (1996), it is not advisable to declare victory quickly despite the team’s recurring wins, despite the motivation derived. The danger with the hurried declaration is due to the fragility associated with new approaches and the likely regression effect. These wins however help the leaders indulge deeper into the intricacies of the organization; discover changes affecting the organizational culture; uncover the organization’s system relationships requiring tuning, and position people in key roles depending on their commitment. Change leaders should indulge in the process with the understanding that their roles will matter for a while (Coutts).
Burns and her team were motivated by the few wins although the nurse-led discharges were not developing at their desired pace. In this case study we see no rewards being given to the individuals that had key roles in the early wins but it’s evident the team is moving ahead despite the few drawbacks associated with policy developments (Coutts n.d., & Flash et al.).
Institutionalize the New Approaches
This stage comes when the change sticks and the implemented strategy becomes a way of doing things in that organization. There is however, a need for sustained pressure so that the new behaviors can remain permanent; otherwise, when the pressure is removed deviations will occur, which will necessitate the use of shared values and social norms. It is important to adapt two factors at this point. One, seeking to convince the people that the improved organization life is due to the new approaches, and two, that new leader should not only believe but also embody the new approaches. In this case study Greens expresses her reluctance to leave the project because she feels it is not secure in another person’s steering. It is evident that the discharge planning is a reality and people in the organization realize its importance and assist in various capacities (Coutts n.d., & Flash et al.).
Planning and Implementation
Unexpected changes in their external environment force organizations to consider reinventing their images. Retrospectively the organizations improve their products and services and change their procedures, policies and strategies to meet their targets. Strategic planning provides structures to consider issues and reach a consensus on how an organization should proceed (Coutts n.d.).
At the planning stage, of the discharge process, Rogers is also invited to bring together the major stakeholders in the hospital. They appoint a leader to steer the admission-to-discharge chain. Burns was able to recruit other individuals who would be vital in implementing the strategy. Burns, Green and the other committee members are able to do background checks on the hospital, by identifying gaps that needed to be filled. Most of the committee members working on the strategy have been in the organization for a long time and are better positioned to clearly understand the strengths and the weaknesses of the hospital. The committee organized group workshops with the participants, thus enabling them to identify certain opportunities that if taken advantage of would reduce the problems the hospital faces.
The frequent meetings and training workshops enabled the committee to identify critical issues that arose as they progressed and thus enabled them to chart a way forward.
Leadership Theory
According to Northhouse leadership as a process involves an individual’s influence on a group of individuals with the ultimate aim of reaching a set goal (2007, p. 13). Many theories of leadership have been used in different situations. Murray (1994) has defined leadership as a group phenomenon involving the interaction between two or more persons in which intentional influence is exerted by the leader over the follows. Hence, the absence of a leader implies the absence of followers, and equally, the absence of followers means there is no leader.
Northhouse (2007, p. 15) indicates that leadership can be a trait or a process; whereby in trait leadership, the individual becomes a leader because of personal characters like intelligence, extroversion or even height; while one becomes a leader by the process of interaction. Leadership is further categorized as assigned: where the individual does not always become a leader but his/her leadership is related to the position that they hold in the organization, or emergent leadership where the individual is supported and accepted by others. Kotter (1996) further outlines leadership as having roles that establish direction, aligning, motivating and inspiring people. The position they hold is not assigned and usually emerges over time through communication behavior.
A look at Rodger Andrews’s leadership indicates that he is a leader by appointment. He is the executive chair of the hospital board. He delegates duties and supports the suggestions brought forward by the team laid out by Burns, his leader of choice. The decision to invite Burn on board implies that Rodger is an emergent leader because he believes that Burns has the capacity to head the change committee despite her lengthy service as a nurse.
On the other hand Sue Green and Tracey Burns are trait leaders. When the admission and discharge chain is handed to her, Burns takes it up enthusiastically. She already had an idea of a solution she saw viable for the organization. She quickly identifies Green as a potential leader and engages her in the workshop that she uses to introduce her intended strategy. She quickly mobilizes the matrons and already has the package of having them relieved from their bedside management duties if they agree to participate in the new strategy.
Despite Burns’ position as an assigned leader, she proves to be equally an emergent leader. The assignment as a leader of the change committee resulted due to her lengthy experience in the hospital. Her designation was purely managerial but due to her long-serving description as a hands-on employee she could hold back but participate in restoring the favorable conditions of the wards and the Accident and Emergency department.
Consequently, her emergent traits were evident through the support and acceptance of other nurses and colleagues into the committee. Not only was she verbally involved in the goings-on within the committee, but was also seeking the opinions of others, such as Green. As the steering leader, her idea generation skills were put to task as she had the necessary background information concerning the hospital’s conditions. The information was vital for her input towards generating new ideas including increasing the voices of nurses and empowering them (Kotter 1996).
Additionally, to imply her accepting people on-board, Burns invites the Director of Management and Technology (IM & T) to help in establishing the information system needed, with the assistance of the Assistant Director Practice development, responsible for availing the data for monitoring progress. It was at this point that Green proved worthy of earning the position to steer the group that would weekly oversee the initiative.
On her part, Green when offered an opportunity to participate in the new strategy takes it up and even brings on board additionally new ideas. She is appointed chair of the committee after she had been working with them for some time. Green took up her role and even without the guidance of Burns she steers the committee towards the intended target. She gets things done when the situation looks bad. Just like Burns’ ascension Green’s bed occupancy exercise that she had previously conducted came in handy as she proved proficient in that area alone. When the Policy development did not bring forth results as expected she chose to take a different route thus saving time in the process (Burns 1978).
Green was also interactive and verbally involved with the operations of the team members. For a period of 30 minutes per week the IM & T Director and Assistant Director Practice Development under the coordination of Sue Green joined the matrons for a review of developments in the discharge projects. Other positions that Sue Green deemed necessary in the discharge projects included site manager, Discharge Manager which as had been Green’s policy, were filled by senior nurses. In addition to changing the bed management duties, the appointing of nurses will aid in relieving the matrons of their responsibilities as they continue the discharge project, uninterrupted.
As an emergent leader Green proves that leadership can be firm but not rigid. While most of her appointees are busy fulfilling the tasks assigned to them, Green is spending the extra time as a priority to support the matrons in discharging their discharge responsibilities. Her strictness ensures that the matrons prioritize their tasks while she is busy building cordial relationships with general managers to foster the achievement of the goals set.
Though the absence of Roger at the hospital is a setback to the team, Green was able to motivate the team to move ahead despite the many challenges (Murray, 1994). At one instance, Burns’ report on the admission of acute patients helped Edwards to secure the required funding for a Reinvestment plan that had been agreed upon. The plan was aimed at equipping the A & E department with physiotherapists and physicians to help assess the patients.
Conclusion
Although the desired strategic change to counter the problems plaguing King Edgar NHS Hospitals Trust did not produce the desired result, the experiences and skills acquired by the various workforce were vital for their careers. In addition to financial and political factors, several other issues hindered the process of restoring King Edgar NHS Hospitals Trust to its desired capacity. Government interventions and bailout packages should be organized for such cases, considering the political influence that contributed to the failure of the institution.
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