Leadership and Strategic Planning in Healthcare

Section A – Leadership Approaches in the Case Study

Question 1 – Leadership Approaches of one of the Key Actors

The Nursing and Midwifery Council (NMC) (2015) highlights that nurses are mandated to deliver patient-centred care based on available evidence-based best practices in the healthcare industry. In this context of evidence-based best practices, NMC (2015) expects nurses to make continuous changes to healthcare services delivery practices and processes to enhance the efficiency and effectiveness of healthcare services delivery in hospital settings. Importantly, nursing leaders are expected to lead changes in healthcare organizations. Implementing change in healthcare organization often encounters numerous barriers and resistances from multidisciplinary stakeholders including nurses, physicians, and social services workers. Therefore, nursing leaders tasked with implementing changes in healthcare organization must utilize leadership approaches that would cause limited resistance to change and yield the expected objectives of change implementation. This paper examines the role of Sue Green as a leader in the case study on “Leading Organizational Change: Improving Hospital Performance” to evaluate how leaders in practical healthcare settings utilize various theoretical approaches during change implementation.

The Leadership Role of Sue Green at King Edgar Hospitals NHS Trust

Sue Green is one of the three Assistant Directors of Nursing at King Edgar Hospitals NHS Trust. The King Edgar Hospitals NHS Trust comprises of three hospitals including Clover Hospital, Friar Hospital, and Bronte Hospital, and Green was specifically placed as the Assistant Director of Nursing at Clover Hospital. Green was recruited into the Assistant Director’s position in October 2002 by Tracey Burns, the Executive Director of Nursing at the NHS Trust. Immediately following the recruitment, Green was tasked with working with key stakeholders within the Clover Hospital and the NHS Trust to address the problem of delays in discharge at the NHS Trust. Sue Green’s role in leadership involved relying on evidence-based best practices and improving partnership with all relevant stakeholders to implement an effective and timely discharge plan at the NHS Trust.

Evaluation of Green’s Leadership Approaches using relevant Leadership Models and Theories

Al-Sawai (2013) described that leaders in the healthcare industry could implement changes effectively by building relationships and supporting all the multidisciplinary stakeholders to work collectively towards common goals. Mitchell (2013) highlighted that healthcare systems comprise of numerous stakeholders with non-linear interactions and with multidirectional goals. The stakeholders comprise of multi-professional groups including physicians, nurses, surgeons, and agents from the Social Services departments. Most of these stakeholders may either accept or resist proposed changes. Thus, Al-Sawai (2013) examined that leaders in healthcare settings must address the diversity of the stakeholders by adopting leadership approaches including but not limited to transformational leadership, Goleman’s Emotional Intelligence style, collaborative leadership, and the situational leadership approach.

Situational Leadership

Lynch, McCormack, and McCance (2011) described situational leadership as a task-oriented approach to leading change that involves adapting a change strategy to the prevailing circumstances that characterize immediate satiations in organizational settings. Lynch, McCormack, and McCance (2011) described that the Situational leadership Theory (SLT) as developed by Hershet and Brabchard (1969) require leaders to flexibly adapt their leadership responses based on the rational understanding of the immediate satiations. Based on the case study, Sue Green utilized situational leadership approach when she adopted the ‘point prevalence’ technique to determine the actual bed occupancy in the hospital’s wards and the expected dates of discharge for each patient. In this context, Green sought to gain a rational perception of the situation in the wards by collecting data from each ward and utilizing the data to determine the actual causes of delays in discharge at the NHS Trust. Therefore, the situational leadership approach utilized by Green enabled her to provide results-informed interventions including creating the new position of a ‘Discharge Manager’ to coordinate the overall discharge process and reduce delays in patient discharge.

Transactional and Transformational Leadership

Besides the situational leadership approach, Green also utilized the transactional and the transformational leadership styles. According to Huston and Marquis (2009), the transactional leadership style is characterized by contractual exchanges between the leaders and the followers whereby leaders create goals for the followers and the followers pursue the goals in a manner that safeguard their self-interests and minimize their work-related anxieties. Transactional leadership approach is suitable for use in change-related situations where short-term goals can be achieved through mutually-beneficial transactions between the leaders and their followers. The transactional leadership style seemed appropriate in the case of the King Edgar Hospitals NHS Trust because leaders at the NHS Trust were concerned with the short-term goal of retaining their ‘One Star’ status after each periodic review from the regulatory authorities.

Sue Green utilized the transactional leadership style when she assigned the lead matrons in the wards to the various discharge improvement projects; thereby reducing the workload of the matrons, but inadvertently increasing the workload of the first-line nurses. However, Green dispelled the work overload anxieties among the first line nurses by informing the nurses that assigning the matrons to discharge improvement projects would eventually increase the voice of nurses in the discharge process and reduce the non-nursing work that had, over ten years, been increasingly assigned to nurses at the NHS Trust. Therefore, the transactional exchange between Green and her followers emerged when Green convinced the first-line nurses that the goals of the discharge improvement projects included reducing the nurses’ workload; hence, safeguarding the nurses’ self-interests.

Also, Green utilized the transformational leadership approach by influencing the attitudes of key stakeholders including the general managers, the social services colleagues, and the physicians. Al-Sawai (2013) explained that the transformational leadership style involves going beyond the mutually-beneficial exchanges in the transactional style and venturing into creating shared ownership of mission and vision by influencing the attitudes of involved stakeholders to subscribe to the shared mission. In particular, Huston and Marquis (2009) explained that transformational leadership requires leaders to convince other stakeholders to raise their consciousness as to transcend their self-interests for the sake of the shared organizational objectives.

In the case study, Green says, “It is very important that I develop good relationships with the general managers…I have to convince them of the importance of the outcomes.” In this context, Green expressed her interest to influence stakeholders including the general managers to buy in to the objectives of the discharge improvement projects. Initially, most stakeholders including the physicians had expressed reservations towards the proposed nurse-led discharge projects. However, Green managed to deploy her transformational leadership skills to convince the physicians to forego their reservations for the sake of the overall improvement of the delays in patient discharge at King Edgar Hospitals NHS Trust.

Collaborative Leadership

Green also utilized collaborative and democratic leadership approaches to bring in the key stakeholders to buy in on the need to adopt the nurse-led discharge at the King Edgar Hospitals NHS Trust. Raelin (2016) described that democratic leadership allows stakeholders to make contributions during decision-making. Also, Al-Sawai (2013) explained that the collaborative leadership style involves providing the necessary information to relevant stakeholders and allowing the stakeholders to make informed decisions. Notably, Mitchell (2013) described that the democratic or the collaborative leadership style encourages dialogue and shared decision-making between the stakeholders, though the leader still retains the role of providing the overall direction regarding the desired change. Mitchell (2013) summarized that the democratic leadership style is useful when co-ordination among multidisciplinary groups is necessary for effective implementation of change in organizational settings.

In the case study, Green utilized the collaborative leadership approach when she championed the use of notification procedures aimed at informing all the stakeholders about the key features and expectations of the proposed nurse-led discharge at the NHS Trust. Also, Green adopted the use of weekly multidisciplinary meetings between internal and external agencies to foster joint decision-making during the design and implementation of the discharge planning. Initially, Green observed that the different stakeholders present during the multidisciplinary meetings were anxious and disapproval towards the prompted improvements in patient discharge. However, Green, as the head of the steering group for the discharge projects, utilized the weekly meetings among the key stakeholders including the senior medical staff, the matrons, and the nurses to promote the ownership of the discharge planning among the stakeholders. Thus, Green utilized the collaborative leadership approach to ensure that all stakeholders provided suggestions to the proposed improvements on the discharge process and that the contributions of all stakeholders were informed through improved communications within the NHS Trust.

Goleman’s 6 Styles of Leadership

Furthermore, Green demonstrated sufficient emotional intelligence that enabled her to shift from one style of leadership to another whenever the situations changed throughout the change implementation process. Desanghere, Saxena, Stobart and Walker (2017) explained that Emotional Intelligence (EI) is the ability for a leader to monitor and understand the thoughts and feelings of the followers. Subsequently, the emotionally intelligent leaders can use the information regarding the feelings and thoughts of the followers to inform the most appropriate courses of action for every leadership context. Desanghere et al (2017) described that Goleman’s work on the six leadership styles including visionary, authoritative, coaching, affiliation, democratic, and commanding emphasized on the centrality of emotional intelligence in informing leaders on when to adopt each or a combination of the six leadership styles to specific circumstances during change implementation.

In regards to the case study, Green demonstrated the ability to discern the stakeholders’ feelings towards the proposed changes and to subsequently adopt a leadership approach that would dispel the negative feelings towards the proposed improvements at every phase of implementing the new discharge process. In particular, Green relied on her emotional intelligence to know when to switch from the democratic leadership style to the coaching leadership approach. During the first preliminary meetings with stakeholders including the executives and the matrons, Green utilized the data from the wards to inform the stakeholders on the importance of improving the discharge process and to encourage the stakeholders to provide suggestions on the most appropriate initiatives to improve the process.

However, Green quickly realized that the matrons tasked with implementing the initiatives were likely to lose momentum in the course of their tasks because Green heard one of the dissenting matrons saying, “I just thought, ‘Oh no!’ Discharge planning is boring…” Thus, Green perceived the negative thoughts of the dissenting matron as necessitating a change of leadership style. Consequently, Green moved from the democratic approach to the coaching approach as exhibited by Green saying, “I continually have to motivate them and make sure that it stays high on their agenda, so I do not let them forget it.” Therefore, Green understood the importance of monitoring the stakeholders’ thoughts and emotions and utilizing the resultant information to inform the need to adopt a circumstantially appropriate leadership approach.

Question 2 – What I would have done differently if I were Tracey Burns

Primarily, Tracey burns nurtured plans to introduce nurse-led discharges at King Edgar Hospitals NHS Trust by implementing changes that would saw the nurses are taking over the responsibility of patient discharges from the specialist physicians. However, the plan by Burns to transfer the responsibility of the discharge process form the medical team to the nursing department was doomed to fail from the start because Burns failed to collaborate with the medical director at the NHS Trust to ensure that the physicians approved the transfer of their traditional duties to the nurses. Burns realized that her attempt to empower the nurses within the NHS Trust had initiated widespread anxieties and change fatigue. The fatigue and the anxieties were worsened by the fact that Burns, in coalition with the general managers of the three hospitals under the NHS Trust, had failed to inform the physicians about the impending changes in the discharge process. Therefore, Burns’ failure to implement the changes on the discharge process successfully and the eventual downgrading of the NHS Trust to a ‘zero star’ health care organization was attributable to lack of interprofessional collaborative leadership on Burns’ side.

If I had been appointed to occupy Tracey Burns’ position at the NHS Trust, I would have solved the problem of delays in discharge by inviting the senior physicians to the first meeting with the Chief Executive where the decision to transfer the discharge duties to the nurses was made. Bosch and Mansell (2015) stated that interprofessional collaborative practices in healthcare are becoming increasingly essential in streamlining healthcare delivery processes and in improving job satisfaction among healthcare professionals. Bosch and Mansell (2015) specified that the element of trust was essential among multidisciplinary professionals involved in collaborative team projects. Thus, Nester (2016) highlighted that effective leaders in healthcare organizations must be able to nurture an atmosphere of trust between multiple professionals to minimize conflicts during collaborative practices.

About the case study, it is evident that Tracey Burns lacked sufficient skills in collaborative leadership because she failed to nurture an environment of trust between the nursing department and the medical department; hence, leading to the anxiety that prevailed during multidisciplinary collaborations at the NHS Trust. If I were Burns, I would have nurtured the atmosphere of trust between the multiple professionals by improving communication between the nursing directors and the senior physicians. In particular, I would have assumed the role of issuing notices directly through formal and informal channels of communications to the senior physicians about the scheduled meetings instead of relying on the general managers to deliver the messages to the medical professionals. Inviting the physicians to the meeting formally and promptly would have allowed the physicians to perceive the nursing directorate as having well-intentioned plans for other professionals within the NHS Trust.

In essence, the move by Burns to make discharge-related decisions and to implement initiatives without consulting the medical professionals created a suspicious notion that the nurses were perhaps trying to take away professional powers from other professional groups within the organization; hence, leading to the mistrust between the nurses and the physicians. Notably, Burns went ahead and enrolled senior nurses including Sue Green, Helen Edwards, and Nikki Thorton to implement the nurse-led discharge processes after the senior physicians failed to cancel their clinics in preparation for the multidisciplinary meeting. Alternatively, I would have called for another meeting instead of proceeding to implement the nurse-led discharge initiatives without the approval of the senior physicians as Burn did. Therefore, Burns erred on her role as a leader in interprofessional collaborative practices; thus, perhaps Burns should acquire further training and education on leadership competencies required for effective multidisciplinary leadership.

Section B – Evaluating the Formulation and Implementation of a Strategic Plan

The healthcare industry is dynamic whereby the needs and the expectations of the healthcare services users change progressively while the tools and processes available to meet the progressive expectations of the users also evolve. Therefore, healthcare organizations must continually plan for the future by developing strategic plans that are intended to address the anticipated changes in the future of the healthcare industry. Strategic health planning involves creating objectives that a healthcare organization would like to achieve in the future and subsequently developing specific operating structures and courses of actions intended to help the healthcare organization to achieve the future objectives. Importantly, developing future objectives and selecting the structures and activities necessary to achieve the objectives is informed by factors that are located both inside and outside a healthcare organization. This section utilizes the 2014-2019 Strategic Plans for Guy’s & St. Thomas’ NHS Foundation Trust to examine the formulation and implementation of strategic plans in practical contexts and to analyse the internal and external factors that influence the formulation and implementation of strategic plans in healthcare organizations.

Guy’s & St. Thomas’ NHS Foundation Trust – The 2014-2019 Strategic Plan

Guy’s & St. Thomas’ Trust is one of the leading healthcare organizations in the UK.  Guy’s & St. Thomas’ provides a wide range of healthcare services including emergency, adult and children specialist, elective, and community services in and around London and the greater southern England (Guy’s and St Thomas’ NHS Foundation Trust, 2018). Guy’s & St. Thomas’ Trust has over 1,000 inpatient beds and employs over 13,500 staff plus over 2000 trainee health professionals. Guy’s & St. Thomas’ Trust earned annual revenues worth £ 1.2 billion in 2017, and the Trust continues to partner with strategic stakeholders including research organizations, volunteer sectors, and social care providers to not only deliver high-quality healthcare services but to also increase its income and remain financially sustainable into the foreseeable future (Guy’s and St Thomas’ NHS Foundation Trust). Thus, the 2014-2019 Strategic Plan for Guy’s & St. Thomas’ Trust describes key activities that would enable the NHS Trust to deliver high-quality healthcare services amidst the rising demand for healthcare in southern England and to remain financially sustainable amidst the funding shortfalls within the National Health Services sector.

Formulation and Implementation of Strategic Plans in Healthcare Organizations

Speziale (2015) described that healthcare organizations were increasingly facing challenges related to two factors including the difficulty in satisfying the progressive needs and expectations of the increasingly ‘aware’ users, and the need to keep pace with the rapid and complex changes in processes and procedures used in the delivery of healthcare services. According to Ginter (2013), these challenges related to the progressive needs of users and the evolution of healthcare delivery processes and procedures are necessitated by the progressively evolving definition of quality and safe healthcare services that place patients at the centre of care plans. Speziale (2015) explained that healthcare organizations must continually devise plans on how to offer maximum value to the users of healthcare services and the lowest cost possible. Thus, strategic planning in healthcare contexts entails continuously realigning the mission, vision, values, and objectives of a healthcare organization to the needs of the healthcare services users and the tools and processes available to meet the needs of the users.

Mission, Vision, Values, and Objectives of Guy’s & St. Thomas’ Trust

The mission for Guy’s & St. Thomas’ Trust as specified in the Strategic Plan is to, “Provide world-class clinical care, education and research that improve the health of the local community and the wider populations that we serve” (Guy’s and St Thomas’ NHS Foundation Trust). Evidently, the mission statement for Guy’s & St. Thomas’ Trust indicates the shift of users’ expectations from a hospital being a ‘treatment’ facility to a hospital being a key stakeholder in ensuring the health and well-being of the local community. Bjegovic et al. (2015) explained that a strategic mission within a healthcare organization should capture the future anticipations of the service users and indicate the intentions of a healthcare organization to meet the anticipations of the users. In its mission statement, Guy’s & St. Thomas’ Trust indicates that it plans to improve the health of the community by not only providing clinical care but by also relying on education and research to develop world-class processes of improving the health of the society. Therefore, the mission of Guy’s & St. Thomas’ highlights the centrality of users’ expectations in the formulation of a strategic framework.

On the other hand, the vision statement for Guy’s and St. Thomas’ Trust is to, “Be a high quality, high performing, and innovative integrated academic healthcare organization…” (Guy’s and St Thomas’ NHS Foundation Trust) In this context, Guy’s & St. Thomas’ plans to improve the quality of its services and the effectiveness and the efficiency of its healthcare services delivery processes by resorting to innovation through academic and professional research. In this context, the vision statement for Guy’s & St. Thomas’ reflects the importance of evidence-based best practices in the formulation and implementation of strategic plans in healthcare organizations today. Jafari et al. (2015) described that the global healthcare industry is increasingly moving towards the use of evidence-based best practices to inform the types of processes and procedures needed to improve the quality of healthcare services as defined by the expectations of the increasingly ‘aware’ users. Therefore, the vision of Guy’s & St. Thomas’ reflects the role of emerging healthcare knowledge and practices globally to inform the design of strategic plans.

Moreover, the values of Guy’s & St. Thomas’ include putting patients first, respecting others, integrity, striving to be the best, and taking pride in the provision of healthcare services. These values are in accordance with the trajectory of patient-centred care that has punctuated the shift of healthcare service delivery from being physician-centred to being patient-centred. In particular, the value of respecting others indicates the emerging importance of ethics and patient satisfaction in improving patient outcomes within healthcare facilities. Lastly, the objectives of Guy’s & St. Thomas’ Trust as captured in the 2014-2019 Strategic Plan include building strong partnerships, efficient utilization of resources, provision of effective and compassionate care, and empowering the staff. These strategic objectives, which specify the specific courses of actions to be used by Guy’s & St. Thomas’ to maximize the value of its healthcare services, are in tandem with the use of systematic and evidence-based courses of actions including interprofessional collaborative partnerships and staff empowerment to streamline the implementation of strategic plans in practical settings.

Factors influencing the Formulation and Implementation of Strategic Plans

The specific objectives of a health strategy are intended to address the prevailing and anticipated dynamics within a healthcare industry. Therefore, the objectives including building partnerships and efficient utilization of resources specified in the strategic plan of Guy’s & St. Thomas’ Trust reflect the prevailing or the anticipated happenings within the internal and the external environments of the Guy’s & St. Thomas’ NHS Trust. Four key strategic plans for Guy’s & St. Thomas’ Trust include to transform care delivery systems, enhance research and development, promote education and training of personnel, and to improve partnership working.

Influential Factors in the Internal Environment: SWOT Analysis of Guy’s & St. Thomas’

Key strengths at Guy’s & St. Thomas’ include a highly motivated staff, efficient financial and operational performances, wide portfolio of healthcare services, and strong partnerships with academic and research institutions. In regards to these strengths, Guy’s & St. Thomas’ plans to sustain the high motivation among its staff by providing training and development opportunities for its clinical and non-clinical personnel. Also, the NHS Trust plans to leverage its efficient performances further by partnering with organizations including volunteering partners willing to provide free services to reduce labour costs at the Trust.

Opportunities enjoyed by Guy’s & St. Thomas’ include the capacity to increase productivity and efficiency, and the chance to strengthen its service portfolio. Thus, the inclusion of strategic plans including the enhanced research and development and increased partnership working are informed by the opportunities available at Guy’s & St. Thomas’.

Regarding weaknesses, Guy’s & St. Thomas’ is struggling with higher costs of services, lack of administrative agility, and suboptimal IT infrastructure. Thus, the 2014-2019 strategic plan outlines the intention for Guy’s & St. Thomas’ to implement supportive strategies including upgrading its IT infrastructure and promoting leadership skills among staff members to address the limited agility in its administrative sector.

Lastly, Guy’s & St. Thomas’ faces identifiable threats including competitive tendering and slow delivery of additional capacity. Thus, Guy’s & St. Thomas’ plans to counter the threat of competitive tendering by efficiently utilizing its resources to cover its low bids in tenders and to counter the threat of slow capacity building through partnership working and education and training of its staff.

Influential Factors in the External Environment: PESTLE Analysis

The 2014-2019 strategic plan for Guy’s & St. Thomas’ was informed by political factors including changing political leadership in the UK including the pre and post-Brexit implications that may shift the healthcare agenda and priorities of politicians; hence, affecting the capacity for Guy’s & St. Thomas’ to work with overseas partners. Thus, Guy’s & St. Thomas’ strategized to increase local partnerships.

Regarding the economic parameter, the higher cost of healthcare services at Guy’s & St. Thomas’ coupled with the declining disposable income among services users and the decreased funding from the NHS may lead to low patient flows in future. Thus, Guy’s & St Thomas’ plans to use its resources prudently to cover any economic changes that may affect its capacity to meet the users’ needs. Thus, Guy’s & St. Thomas’ seeks to improve its IT infrastructure to optimize the efficiency of its resource utilization systems.

Regarding social and cultural factors, Guy’s & St. Thomas’ is cognizant of the fact that the local population demands to be included in the active planning and implementation of community-based healthcare initiatives (Zuckerman, 2012). Thus, Guy’s & St. Thomas’ Trust intends to factor in the diverse cultural expectations of communities living in southern London.

Regarding technological influences, Guy’s & St. Thomas’ Trust appreciates that the technologies available for delivery of healthcare services are evolving rapidly. Thus, the NHS Trust seeks to revamp IT infrastructure and to strengthen its research and development efforts to remain up-to-date with technological developments in the healthcare industry.

Lastly, Jafari et al (2015) described that the legal influences behind the strategic plan include the increasing litigation following medical errors in healthcare facilities. Thus, the NHS Trust plans to reduce the need for litigations by providing safe and productive care. Regarding environmental factors, Guy’s & St. Thomas’ Trust acknowledges the volunteer programs ran by environmental sustainability organizations. Thus, the NHS Trust plans to work with local voluntary organizations to streamline the environmental sustainability aspects of its healthcare processes.

In conclusion, the five-year strategic plan for Guy’s & St. Thomas’ Trust indicates the central role played by both internal and external environmental factors in influencing the formulation and implementation of strategic objectives in healthcare organizations. Internal factors including the availability of resources and the efficiency of services delivery processes influence the types of courses of actions to be included in a strategic plan. Similarly, external factors like reduced funding from the national government will inform the inclusion of strategic courses of actions necessary to safeguard the financial sustainability of a healthcare organization in times of funding reductions. Overall, the formulation and implementation of strategic plans in the healthcare industry is guided by the anticipated changes in the expectations of the healthcare services users and the evolution of mechanisms and tools for delivery of healthcare services globally.