How a programme to reduce waste, improve efficiency and increase the amount of time staff can spend on patient care was rolled out to hospital wards
Kerry Bloodworth, MA, PGCE, RSCN, RGN, is assistant director of nursing, Nottingham University Hospital.
Bloodworth, K. (2009) Productive Ward 1: implementing the initiative across a large university teaching hospital. Nursing Times; 105: 24, early online publication.
The first in a two-part series on how to implement the Productive Ward initiative, this article looks at its implementation across a large teaching hospital.
Keywords: Management, Leadership, Lean, Organisation
- This article has been double-blind peer-reviewed
- Download a print-friendly PDF file of this article here
The Productive Ward is a national initiative developed by the NHS Institute for Innovation and Improvement (NHSI). It aims to motivate ward teams to review the way in which activities are undertaken in the workplace, with the goal of removing waste and releasing time to provide more direct patient care.
Research carried out by the NHSI found that ward nurses in acute settings spent an average of 40% of their time on direct patient care (NHSI, 2007). This is supported by research carried out by Nursing Times, which found that nearly three in four ward nurses said they did not spend enough time on direct patient care, with 90% of those polled saying that patient care suffered as a result (Evans, 2007).
The Productive Ward programme adopts ‘lean’ principles that are used in the manufacturing industry. Lean is described as a sustainable method to improve quality, cost-effectiveness and delivery of goods and services. Healthcare organisations are beginning to adopt lean principles as a vehicle for continuous improvement.
The lean methodology is also aligned with High Quality Care For All:NHS Next Stage Review (Department of Health, 2008), which set out a new foundation for a health service that empowers staff and gives patients more choice. It said that future healthcare services should be personalised and fair, include the most effectivetreatments within a safe system and help patients to stay healthy.
Here, Lord Darzi described the need to ‘move from an NHS that has rightly focused on increasing the quantity of care to one that focuses on improving the quality of care’. He established a framework for systematically improving quality, based on clarity, quality standards, measurement, publication, recognition/reward, safeguarding quality and staying ahead.
Miller (2005) said that medical care had similarities with manufacturing as both involve complex processes, and gave examples of organisations that had made significant improvements in financial management and patient safety by applying the lean philosophy.
Following some initial improvements as a result of using lean techniques in health care, the NHSI has developed a number of products called the ‘Productive Series’, which aim to standardise approaches to improvement.
The Productive Ward
The Productive Ward is one of these products. It is a self-directed programme comprising 11 modules (Fig 1), providing tools and guidance to help nurses make changes to their physical environment and working processes that will improve the quality of care and raise safety standards. The approach, which uses improvement techniques from the manufacturing industry, analyses the main tasks taking place on a ward. These tasks, such as medication and meal rounds, are then redesigned to ensure they are patient focused and easier for staff to perform.
The programme often focuses on simple ideas, such as altering patient handover times, reorganising storage facilities and making better use of data. It also provides a systematic and inclusive approach to improving the reliability, safety and efficiency of the care delivered in a ward. For example, the Well-Organised Ward module takes an approach to simplify the workplace and reduce waste by ensuring that everything is in the right place at the right time. Part of this process is called 5S (Box 1).
The programme is designed to provide long-term sustainable changes to ways of working that are constantly revisited. It takes 1–2 years to work through the modules - this length of time ensures that changes are driven and implemented by ward sisters and have been adequately thought through and are sustainable. The module tools empower front-line ward staff to own and embed change, and to routinely question procedures.
Benefits of implementing the Productive Ward
The core objectives of the programme are to:
- Increase the clinical time spent with patients;
- Enable safer and more reliable care with fewer healthcare-associated infections and falls, and improved quality of patient observations;
- Improve the experience of staff and patients by asking for their views and opinions;
- Organise wards so they work more efficiently;
- Reduce interruptions and improve communication;
- Reduce the time taken in handovers and ensure clear lines of accountability.
The Productive Ward provides performance measures designed to track how wards are performing against these core objectives.
Nottingham University Hospitals NHS Trust (NUH) was formed in April 2006 from a merger of two large hospitals, Nottingham City Hospital and the Queen’s Medical Centre. The Productive Ward provided an opportunity for the trust to engage nursing and midwifery staff in delivering better quality care in a consistent manner throughout the organisation.
The NHSI had developed and tested the approach on wards at four test sites, which tested different Productive Ward modules on one ward. The next step for the institute was to test a prototype toolkit on a whole hospital; NUH is one of two national pilot sites – the other is Central Manchester and Manchester Children’s University Hospitals NHS Trust.
The programme of work at NUH started in September 2007 and the plan is that 96 wards will have implemented the programme by summer 2010. With the support of the NHSI, the summer of 2007 was spent planning the project. To do this, we needed to:
- Recruit two project nurses;
- Organise a steering group;
- Communicate with ward sisters;
- Learn the lean concepts;
- Plan the project’s roll-out on wards.
At the time we had no idea what was involved in the implementation of the Productive Ward modules because many were still being written. This was a challenging time as the official launch date for implementation on the wards was January 2008.
The executive team supports the initiative and the chief executive and director of nursing, midwifery and service improvement are the main sponsors and drivers. The trust board is also supportive and some non-executive directors are actively involved in the project’s implementation.
The project steeringgroup meets every month and has been key to the success of the project (Box 2). Ward sisters attend the steering group to share their experiences of implementing the Productive Ward and provide essential feedback. Patient representatives have also been involved.
The project is managed by the assistant director of nursing and the key function of the project leader is to plan and implement its roll-out. The project team realised that effective project management requires extensive planning and coordination for the Productive Ward to be rolled out successfully (Fig 2). The project plan has an eight-ward roll-out every 9–10 weeks, with facilitated learning support from the project nurses for 13 weeks. This allowed for some time to review and reflect, and enabled the project team to help ward teams with implementation.
Over time, as the number of wards involved in the programme increased, funding for two more project nurses was secured.
Ward staff were told about the project in a short presentation and were invited to apply to take part. The application process was simple, with two short questions that enabled the ward sister to think about how the ward would benefit from this programme of work:
- Why would you like your ward to be chosen for the Productive Ward?
- How would you release staff in order to benefit from the Productive Ward programme?
The project team received 42 applications in the first three weeks, which demonstrated the enthusiasm and willingness of ward staff to review how care was organised. The completed application forms gave an insight into how the ward sisters would manage a programme of change and the outcomes they wanted for their wards.
We used the application form process to choose only our pilot wards and the first cohort of eight wards. Other wards were phased into subsequent cohorts. Ward sisters who submitted an application form were visited by a member of the project team, who provided detailed information about the Productive Ward and gave them some choice in deciding when their ward would start the programme.
So far, all the wards have volunteered to undertake the Productive Ward programme and the drive has come from ward sisters as they have witnessed their colleagues achieve positive results from implementing the modules. We regularly update ward sisters on the Productive Ward’s progress and this communication continues to attract more wards.
Evaluation of ward progress using an audit tool
As the programme was rolled out, a model of sustainability was developed to embed the changes wards had made. We also wanted to share successes among the ward teams and give ward sisters information about what else they needed to do.
There is little information available about measuring the sustainability of the Productive Ward and the impact of any changes, so we decided to devise our own audit tool. This measures staff engagement and the project’s progress, and was piloted with cohort 3 (Fig 2). The tool has been reviewed and refined as the project progressed, and matrons use it to monitor progress when the project team leaves a ward. This enables the wards to continue to set their own pace as they implement modules.
The aim of the audit is for wards to score over 79%. If they fall below this the ward teams develop an action plan. The tool also measures and demonstrates the progress made by ward sisters during their three-month block of coaching and facilitation from the project team. This information gives them the confidence to continue implementing the modules until all 11 have been completed, and identifies when a ward sister needs support.
Performance measures are designed to measure and track how wards are performing against the core objectives of the Productive Ward.
The Knowing How We Are Doing module provides measurement systems that are useful to the ward staff (Box 3). The teams assess themselves and track how their wards are doing against the Productive Ward measures.
The Productive Ward data spreadsheets are held in a central shared area, with some held at ward level and some displayed on the ward. Not all nursing staff found it easy to handle and interpret data initially, and needed briefing and coaching. The data is aggregated in each cohort to highlight trends by the addition of a trend line (Figs 3-6). The aim is to demonstrate any improvement in measures, for example, falls, pressure ulcers and clinical observations.
A project fails when it overruns, underperforms or is not implemented. As a project team, we realised there was a need to assess potential risks to the scheme. A project risk assessment was performed to ensure that we had a realistic plan. One of our key aims is to share our learning of implementing the programme with the NHSI and other trusts.
Delivering measurable impact
We need to ensure there is a relentless focus on delivering measurable improvements to patient care and staff productivity/efficiency. Unlike some other trusts, we are about to provide staff with real-time data such as length of stay and discharge information. This has given ward teams information that enables them to actively address areas of concern. Previously performance data was retrospective and difficult to interpret and use for problem-solving.
Pace of change and sustainability
Change needs to continue after the project team leave the ward, because it takes time to embed new habits and working practices.
The sustainability scoring tool has been modified for the matrons to use every month. This will enable matrons to clearly see the continued progress of wards and highlight areas of concern – and also to celebrate successes.
Ward managers, including matrons and senior nurses, need to be trained in Productive Ward concepts so they can act as role models, coach their staff and integrate the Productive Ward outcomes into the business of the directorate.
We have provided initial training, tools and facilitation to ensure that the ward managers/ward sisters are equipped to lead and are confident about their role. Action learning supports the ward sister to continue to implement the remaining Productive Ward modules when the project team have left. To support ward sisters, training has been given to staff nurses to help them lead and implement a module.
Links to trust-wide systems and processes
As the number of productive wards increases, a conflict of interest may arise with some of the hospital-wide support services. It is challenging for the support departments to understand and appreciate ward requirements as they will have to implement the 5S work in their room and storage areas (Box 1). For example, estates services need to be flexible and responsive so that they can make minor alternations to wards, such as moving a sluice or fixing shelves.
A quality improvement and operational change programme such as Productive Ward enables an organisation to concentrate on and reassert its core purpose, gives back control to staff, and involve the whole organisation.
Leadership and commitment from the top is essential to its success, as initiatives such as this are about changing the whole organisation, not just tinkering with systems and making small improvements.
- Part two of this series, to be published in next week’s issue, describes the role of the facilitator in implementing the Productive Ward initiative.
Box 1. The 5S approach
5S is a series of steps that aims to create an ideal workplace by organising, cleaning and reducing waste. It is based on translations of five Japanese words:
- 1S = seiri = sort: separating needed and unnecessary, eliminating unwanted material
- 2S = seiton = set: a place for everything and everything in its place
- 3S = seiso = shine: cleaning, eliminating dirt, making like new
- 4S = seiketsu = standardise: procedures and responsibilities
- 5S = shitsuke = sustain: making compliance automatic, a habit
Box2. Project management structure
|Productive Ward project steering group||Project implementation team||Ward teams|
Box3. Data from Knowing How We Are Doing module
|Improve patient safety and reliability of care||Quality of patient observations|
|MRSA/C. diff infection rates|
|Improve patient experience||Patient satisfaction|
|Improve the efficiency of care||Direct care time|
|Length of stay|
|Bank and agency hours employed|
|Improve staff well-being||Unplanned absence rate|
Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final
Report. London: DH.
Miller, D. (2005) Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement.
Evans, R. (2007) Releasing time to care: Productive Ward, survey results. Nursing Times; 103: 16 (supplement), S6-9.
NHS Institute for Innovation and Improvement (2007) Releasing Time to Care: The Productive Ward. The Prototypedevelopment phase. Participant Information. Coventry: NHSI.