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 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.