South Devon NHS Trust has been in operation for several years and offers various key services. The unit of interest at the facility is the stroke unit that had been designed for handling acute cases, but several constraints in the unit necessitated change. Consequently, the corporation resolved to work towards a collaborative solution to the existing challenges. Amidst barriers such as financial constraints and resistance from different stakeholders, Jenkins managed to develop a strategy for change. Both anticipated and unexpected challenges contributed significantly to progress in the efforts towards change, and success would have been impossible without strong operations management capabilities. specific shortcomings of the existing model, such as system delays and increased waiting times were addressed through changes, overcoming challenges and enhancing collaboration among healthcare providers.
- Key Events and Details
The National Health Service (NHS) South Devon Health Services Trust stroke unit at Torbay General Hospital was initially designed for acute care for stroke patients. However, the unit had been used to cater for services to both acute care stroke patients and stroke patients in need of rehabilitation. Additionally, unit addressed the needs of patients with other neurological disorders, resulting in capacity constraints. Nevertheless, the stroke unit faced various challenges resulting from capacity constraints, and the challenges were linked to multiple factors, including prolonged hospital stay among acute stroke patients, which resulted in high occupancy levels and low to moderate admission rates (Battilana, Cagna, D’Aunno, and Gilmartin 2006a). The systems did not comply with the NSF capacity guidelines, yet it was difficult to finance further expansion to the unit within a short time given that funds had recently been used to improve the system (Battilana et al. 2006a). Two options were available for addressing the capacity constraints in the stroke unit: Expanding the existing stroke unit and re-allocating the rehabilitation services for the stroke unit to another facility. Because of the existing financial constraints, the second option was chosen.
- Case Context
The need for capacity enhancement at the stroke centre came at a time when various changes were occurring in the healthcare sector. The NHS, for instance, had a plan to which all healthcare facilities had to adhere to centre services around patient needs. For the stroke centre, this regulation required adequacy in spacing and that all stroke patients be attended to by a stroke specialist (Battilana et al. 2006a). NHS policy on stroke management was based on the fact that stroke consumed nearly 4% of total NHS expenditure annually, was the single major cause of disability across the country with nearly 250,000 people affected at any given time, and resulted in approximately 60,000 deaths annually (Battilana et al. 2006a). These statistics explain the emphasis placed by the government on expanding stroke capacity and improving care outcomes. Other aspects of importance at the time included public focus on care quality and the implementation of healthcare facility rating systems based on service quality. Stroke care systems have also
- Case Questions
Challenges and Characteristics of Effective Chronic Care Systems
Shortcomings of the Existing model
The main shortcoming of the existing model was the existing care capacity, and propositions were made to resolve the matter. Rehabilitation patients were many compared to acute care patients. At the same time, the unit had been designed to serve the needs of acute care stroke patients rather than the patients in need of rehabilitation. Therefore, it was impossible for the unit to attain the required achievements for rehabilitation under the NSF guidelines, and consequently, it was proposed that stroke patients requiring rehabilitation be handled outside the unit to increase capacity for acute care, for which the unit had been designed. The same approach could be adopted for handling patients with other neurological conditions, who may need admission. According to Battilana et al. (2006a), shifting the rehabilitation care of stroke patients to other units would be an indication of potential overhaul of stroke care, which would undoubtedly raise resistance among various stakeholders. Taking this option would therefore require proper change management practices in dealing with patients as well as healthcare personnel to avoid resistance and potential sabotage of the plans.
The second shortcoming was inefficiency in service delivery, which inconvenienced patients. The most pronounced pointer to this inefficiency was the prolonged stay of patients in the unit. Stroke patients admitted to the acute care unit underwent rehabilitation for up to 21 days, a period considered to be unnecessarily long (Battilana et al. 2006a). Patients also relied solely on discharge by the consultant stroke specialist in spite of the presence of physicians who worked with them daily and coordinated with the consultant specialist. Thus, there was unnecessary capacity utilization, which could be reduced by reducing the length of stay in the acute unit. According to Battilana et al. (2006b), one of the implemented solutions was to hire an allied consultant specialist to head the stroke unit and to increase the staffing of the unit. Additionally, operational efficiency was improved by implementing coordinated efforts to ensure that all patients met admissions and transfer criteria for the stroke unit. The outcomes of such changes were expected to be improved care outcomes, reduced durations of hospital stay and enhanced patient-handling capacities.
Characteristics of an Effective Chronic Care System
The proposed and executed changes at the Torbay General Hospital stroke unit and the affiliated Tudor ward at Newton Abbot Community Hospital were aimed at improving the facilities towards adherence to the NSF guidelines. The specific goals for the changes included increasing the throughput of stroke patients admitted to the unit, enhancing community rehabilitation services for stroke patients, developing and integrated work cultures built on inter-departmental collaboration, and transforming the discharge practices (Battilana et al. 2006a). Each of these goals is aligned to the conventional effective chronic care model. For instance, Strickland et al. (2010) suggests that an effective chronic care model should be characterized by various elements, one of which is the healthcare organization. The healthcare organization must be the central element in the chronic care model, and ought to reflect a culture that is focused on the delivery of patient-centred care. According to Battilana et al. (2006a), the NHS South Devon Health Services was initially developed to cater for the healthcare needs of the community, with patient-centred care at the core of effective service delivery. Indeed, deliberate efforts have been made in the past to ensure that the facility meets the evolving needs of patients, through provision of quality services, adequate staffing, and support for chronic cases (Battilana et al. 2006a). The decision to involve Fiona Jenkins in the redesign of the stroke unit is another indication of the facility’s focus on sustaining its status in patient-centred care.
Other elements that characterize an effective chronic care system have been discussed n the case. These include decision support, design of the delivery system, community resource linkages, and self-management support among others (Strickland et al. 2010). Delivery system design relates to the consideration of key factors of efficient service delivery, catering to the needs of patients such as by adhering to the capacity and care quality standards outlined in federal and state laws (Foo et al. 2015). The commitment to effective design of the delivery system is best observed through intentional efforts to align the healthcare delivery models to the patients’ needs, such as increasing staffing to increase attention on patients, establishing seamless patient transfer protocols, developing standardized procedures for multidisciplinary collaboration in patient care, and working with patients towards achievement of their treatment goals particularly in rehabilitation (Shukla, Keat and Cegralek 2014). Focus on various aspects of health improvement, including prevention, health promotion, treatment, and education, helped provide evidence of the intentional structuring of the service delivery system towards effectiveness in patient care. Community resource linkages are characterized by the identification of the contributions of different community resources to patient well-being (Strickland et al. 2010). identification of the areas of community input is made possible and chronic care systems can achieve better collaboration in healthcare service delivery through collaboration with different community stakeholders. Actions such as visits to other community facilities for benchmarking help in the development of initiatives towards community resource linkages.
Various factors contributing to the efficacy of healthcare service delivery are also described as part of the conventional effective chronic care system. According to Shinto (2018), ability to identify high-risk patients, embedded care within primary care teams, empowered care managers who can close existing healthcare delivery gaps, patient education, and active outreach to patients, constitute characteristics of effective chronic care systems. As such, there should be continuous efforts towards improvement. The recognition of the need for this continuous improvement and its impacts on healthcare delivery, as exhibited in Battilana et al. (2006b), is an indication of the intention towards progress in service effectiveness. Therefore, the chronic care system becomes more holistic with the combination of effectiveness, facility and community factors.
Handling Organizational Issues on Power and Politics
One of the biggest challenges to organizational change in any organization is resistance. From the onset, Fiona Jenkins recognized the probability of the mentioned issue, and her comments regarding her thoughts about the resistance indicate readiness to address them head-on. The resistance was considered to have been even more probable had she been working in only one facility prior to the project management role in the redesign of the stroke unit. Working in an inter-organizational committee gave her an advantage as the stakeholders to the project were familiar with her. Nonetheless, she still faced certain resistance, particularly attributed to feelings of intimidation within the teams. The team at Torbay General Hospital felt that it would be compelled to change their work location to Abbott Community Hospital, a change it was not ready to make. The resistance challenge is a common one in organizational settings as reported by Jones and Van de Ven (2016). Moreover, the issue is often influenced by the desire to maintain the status quo, lack of information on the need for change, and inter-team conflicts. Understanding the cause of resistance can help in developing effective strategies towards management of the change process.
As a change manager, Jenkins performed exceptionally in managing the expected resistance. The first step was to initiate team involvement in the form of the steering committee, which included nurses, the regional coordinator of the stroke association, patients and social service representatives. The action aligned to the argument that employees and other stakeholders to organizational change would resist a change prospect if they were not involved in the change process (Edwards and Saltman 2017; Nilsen et al. 2019). The use of benchmarking techniques and educational approaches to create awareness of the need for change is another practice that confirmed Jenkins efficacy, as Edwards and Saltman (2017) purport that lack of awareness is another factor that results in resistance to change in healthcare organizations. With representations across all categories of stakeholders and effective communication on the need for and objectives of the change, Jenkins used her power as a project manager to earn the buy-in of the respective leaders and subsequently of other stakeholders, which was a really important step towards success. These actions helped to gain significant tract and confirmed the effectiveness of Jenkins as a change manager.
Jenkins also faced unprecedented barriers to organizational change. One of these was the differences in needs and lack of communication across the teams. Besides the resistance to change, it would be difficult for Jenkins to attain traction in systems redesign within an environment in which team leaders do not communicate with one another. Lack of communication can result in many problems in a team, including lack of support to the initiatives of others and intra-team conflicts (Mares 2018). Communication is important in enhancing the efficacy of teamwork in healthcare not only for the redesign project but also for any other change initiative that would be taken (Babiker et al. 2014). Jenkins initiated discussions on the importance of communication within the team to address this issue. To address the differences in needs, she facilitated unity in purpose through benchmarking, collective reporting and collaborative planning. In this way, she hoped to eliminate the difficulty that would have been faced in convincing a team with different visions to adopt a new structure when the team members do not communicate amongst themselves.
- Vision and Communication Strategies
Considering Jenkin’s ability to initiate and facilitate change in the organization, she is a strong leader with excellent change management skills. Specific aspects of her approach that worked perfectly included the communication strategies implemented within inter-team groups, effective coordination skills, and the development of a clear and unified vision for the team. Kitch (2017) avers that clarity of vision is one of the elements of great leadership, and that unity of that vision across the teams helps to steer collaborative progress. Jenkins seems to have recognized the mentioned sentiments hence her ability to recognize the diverging visions across the team and to direct the team using a series of consolidated goals. Nonetheless, she could have improved on the implementation. Particularly, it would have been necessary for Jenkins to develop a plan for continuous improvement rather than limiting her focus to the redesign and implementation of the first stage of progress.
- Outcome Measures
The success of the change project implemented by Fiona Jenkins was measured based on an increase in the capacity of the stroke unit both for rehabilitation and acute care management in alignment with the NFS guidelines. With the initiation of the rehabilitation unit at Abbot Community Hospital and the recruitment of an allied stroke specialist consultant, significant achievement was realized in capacity improvement. Additionally, patient outcomes could be measured based on data such as duration of hospital stay per patient (an improvement from the 21 days would indicate positive outcomes); increased patient throughput to the unit; and improved case-based allocation of patients to specific units. According to Bekker, Koole and Roubos (2016), flexible bed allocation has various drawbacks, such as the absence of focus and potential deficiencies in service delivery. case-based allocation to hospital wards thus helps to improve capacity management. These measures will not only help to monitor progress but also to identify areas in need of further change.
Capacity management in a healthcare facility is a concern shared among many healthcare organizations. For NHS South Devon Health Services stroke unit, effective change towards capacity improvement was based on the identification of the challenges and gaps in the organizational capacity management. The project manager faced various challenges, including resistance to change and ineffective team communications. Such issues were handled through effective stakeholder education, team engagement, and fostering effective communication among team members.
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