A practical guide for those involved in rolling out the Productive Ward initiative, including preparation, modules, training and outcomes
Pete Allsopp, RN; Joe Faruqi, RGN; Laura Gascoigne, RGN; Rachel Tennyson, RN; are all project nurses, Releasing Time to Care, Nottingham University Hospital.
Allsopp, P. et al (2009) Productive Ward 2: practical advice to facilitators implementing the programme. Nursing Times; 105: 24, early online publication.
This is the second in a two-part series looking at the implementation of Productive Ward. Part one looked at roll-out of the initiative across a hospital. This part offers advice to facilitators involved in implementing the programme.
- This article has been double-blind peer-reviewed
Keywords: Facilitation, Change management, Quality
‘Not another fancy idea from management,’ is often the first reaction to any new initiative, followed by ‘Don’t they think we’ve got enough to do?’ and ‘How am I going to release staff to do this?’
The Productive Ward programme addresses these concerns by empowering staff to take control and make changes to their wards.
It is a national initiative by the NHS Institute for Innovation and Improvement (2007). The aim is to help teams review the way in which key activities are carried out on wards to remove waste and release time to provide direct patient care.
The Productive Ward programme consists of 11 modules: three foundation modules and eight process modules. Foundation modules are implemented first and then the process modules in any order.
The macro plan for rolling out Productive Ward across Nottingham University Hospital was described in part 1 of this series (Bloodworth, 2009). The aim is to roll-out the programme on 72 wards in two years.
Role of facilitators
Two project nurses were appointed at Nottingham University Hospital to facilitate the roll-out of Productive Ward and this was increased to four as more wards implemented the programme.
The key role for the facilitator is to work with staff to use improvement techniques and ensure that the principles underpinning the initiative are taught, understood and implemented on the ward.
At Nottingham University Hospital wards receive an initial period of 13 weeks’ support from the project nurses as the foundation modules are implemented. Modern matrons then assume the role.
Training and development for ward sisters
Implementation of Productive Ward modules and the responsibility for leading a major service improvement project require a defined set of skills that some of the ward sisters do not have.
A supportive programme has been devised for them, which includes action learning, key service improvement skills and regular workshops to provide ongoing support.
Some ward sisters received leadership training before Productive Ward was implemented to enable them to develop the skills to implement, communicate and manage change within the clinical environment.
We have identified a number of issues that need to be considered before the initiative is implemented.
- Have the ward teams agreed a standard for communication?
- Are resources available to make changes, for example input from estates to redesign storage areas?
- How quickly does change need to happen?
- How can improvements be sustained?
- Who is responsible for maintaining the pace of change when project nurses have moved on?
- How can the impact of any specific change be measured?
- What are the roles and responsibilities of the ward sister and matron?
- How will the organisation help to overcome obstacles that prevent change?
- What method can be used to monitor project implementation?
At Nottingham University Hospital, we attempted to learn as much as we could from implementing the programme on two showcase wards and the first two cohorts of eight wards.
The showcase wards had approximately five months’ facilitation for one day a week. Cohort 1, consisting of eight wards, received 18 weeks of half-day facilitation and cohort 2 had 15 weeks.
It was felt that wards/units would not benefit from having full-day facilitation as they could not release staff for full days to implement the project.
Preparing for a ward
Three weeks before a ward is scheduled to start Productive Ward, the team meet a facilitator and plan the implementation.
An event for ward teams is held on the first day of the ward preparation phase and the project team runs briefing sessions for ward staff.
Points for preparation are listed in Box 1.
Box1. Preparing for Productive Ward
- Give the ward advance notice of joining the project – invite the senior ward team to launch the event.
- The facilitator needs to prepare the ward sister.
- Give the ward sister 3–4 weeks to prepare the team, for example, watch a DVD about Productive Ward, write a ward vision, undertake ‘activity follow’.
- Encourage the ward to formulate a communication strategy between ward management and the rest of the team.
- Tell the ward when facilitators will visit, for how long, what will happen during the visit, who needs to be involved and what needs to be done between visits.
Support to implement the three foundation modules and up to two process modules takes place in 13 weeks of half-day facilitation. The facilitator’s main objective is to equip staff with the necessary skills and knowledge to continue the programme without support.
Pre-implementation work for the ward sisters
Before the programme begins on a ward the sister needs to:
- Start safety crosses. These measure falls, pressure ulcers and MRSA and Clostridium difficilerates. Specialist areas develop their own safety checks;
- Collect baseline data – staff sickness, staff and patient satisfaction and an audit of observation charts. This data can then be used to inform staff about their progress;
- Do an ‘activity follow’ – follow one nurse for a 12-hour shift and document what they do every minute. This is part of the baseline data to provide a snapshot of a typical 12-hour shift highlighting interruptions and time spent with patients;
- Order equipment, for example display boards. These are essential for the ‘knowing how we are doing’ module as well as for communication;
- Teach staff the 5S approach (Box 2);
- Introduce the project to staff.
Box 2. 5S approach
Sort: Separate what is needed from what is not needed. Keep only what is needed, in only the amounts needed.
Set: Arrange needed items so they are easy to find and use. Label items so their storage sites are easily understood by anyone, so there is ‘a place for everything and everything in its place’.
Shine: Remove dirt, mess, clutter and dust from the workplace. Agree this is the minimum standard you are willing to accept for the area from this point onwards.
Standardise: Operate according to room standards and procedures.
Sustain: An audit/checklist completed daily to begin with, then weekly/monthly as changes become the norm.
During the period of facilitation it is important that the ward sister has ownership of the process so that momentum is maintained when facilitation is withdrawn.
The ward sister responsible for implementing Productive Ward needs to:
Make time for implementation and stick to it;
- Follow the project plan;
- Get all staff involved;
- Engage the support of the matron to help sustain and support the project after the facilitation phase;
- Meet with other ward sisters to solve problems together;
- Incorporate other policies that work alongside and complement Productive Ward including Essence of Care and Saving Lives.
Advice for the project facilitator
This includes the following points:
- Facilitators are there to facilitate, not to do;
- They need to have a plan for each visit to a ward and stick to it;
- It is important to leave a task list at the end of each visit to be completed by the next visit;
- The ward leader and the team need support as change can be a challenging experience;
- Get a balance between allowing staff to innovate but ensuring safety. For example, symbols used on patient information boards such as nil by mouth and nutritional requirements need to be standardised across the trust to ensure safety;
- Be patient, as ward teams have to work matters out for themselves.
Keeping staff informed
Nottingham University Hospital has a chief executive and director of nursing who fully support Productive Ward. Monthly steering group meetings involving senior management team members give ward managers the opportunity to discuss successes and any difficulties they encounter which may need executive team support.
As the project has gained momentum, we tell hospital staff about Productive Ward in a number of ways, including:
Poster presentations at every ward manager time-out day;
Briefing sessions to all staff: nurses and allied health professions, estates and facilities, materials management team and student nurses at the university;
- ‘How to lead on a module’ study day;
- Weekly presentation at registered nurse time-out days and non-registered staff time-out days;
- Sessions at directorate induction days;
- Lean study days for matrons/practice development matrons and clinical leads;
- Sessions on practical problem-solving;
- Involvement in strategic health authority and national events.
Post-facilitation project plan
Initially, little thought was given to the pace of implementation of modules when the facilitated phase ended.
However, it became apparent that wards were unlikely to continue to implement change at the same pace of the first 13 weeks. Wards often stopped releasing staff to work on the project.
To try to address this, the following questions were identified:
- Who is accountable for pace of implementation?
- What should the pace be?
- What barriers are there for ward teams?
- Are knowledge and skills of ward staff and those supporting the project such as matrons sufficient to sustain it?
Initially, it is very easy to monitor the progress and status of a few wards. When there are 10 or more wards at different stages of implementing Productive Ward, a structured approach is needed.
A tool called ‘Project Status at a Glance’ helps the facilitators tofocus time where it is needed and identify areas that have managed to make progress and others have struggled. This involves using a traffic-light system of green (on target), amber and red to highlight progress.
Barriers to implementation include:
- High patient dependency;
- Poor staffing;
- High vacancy rate;
- Change in ward management;
- Resistance to change;
- Lack of leadership.
Implementing foundation modules
Knowing how you are doing (first foundation module)
Wards develop aperformance board where measures including falls, infection rates, staff sickness and other measures can be displayed.
The team holds weekly meetings to discuss their performance. This helps them to focus and direct resources and develop clear action plans for improvement. The information on the board helps staff to understand how performance and practice will directly influence the measures.
The information is on public display, which shows visitors that the ward is committed to improving performance and patient care. Displaying timely data ensures a timely response to any problems as well as giving the team positive feedback.
The well-organised ward is an approach to simplify the workplace by having everything in its place, at the right time, in the optimum amount.
It is not a tidy-up, which usually entails removing any unwanted items and having a general clean or a refurbishment.
It requires the implementation of the 5S (Box 2).
5S is about continual improvement. It is engaging, visual and, as change is quickly achieved, staff feel positive about it. It is important to stress the benefits of 5S, for example, less walking around, time saved, improved infection control practices and cost saving due to a reduction in stock levels. Before and after photos are important as staff quickly forget what the room was like before the change (Fig 1).
Patient status at a glance
The greatest number of interruptions for staff that we observed during this project in a 12-hour period was over 200, nearly one every three and a half minutes. We found that, usually, 30–40% of all interruptions are related to patient status, for example, around discharge information, dietary needs or the patient’s ability to walk.
Visually displaying the right information on a ward whiteboard or on boards behind beds can dramatically reduce interruptions, improve communication within the team, improve safety, speed up discharge and reduce time spent looking for information.
We encouraged our first three cohorts to develop their own ward whiteboard and boards behind beds.
Wards could write information or use simple symbols to represent key information. As a consequence, they developed their own signs and symbols and, as a project team, we faced our first major conflict between the competing needs of innovation versus standardisation. It was necessary to standardise the format of these boards, as a symbol on one ward’s board could mean something very different on another. This introduced an unacceptable risk into the system.
We met with the 26 ward managers and developed the trust standard for ‘patient status at a glance’ boards.
We tried not to be too prescriptive – a certain degree of flexibility is still needed to enable wards/units to display key information that suits their wards’ specialty.
This work has developed and the aim is to use fully networked electronic whiteboards for patient status information.
All the process modules are based on the PDSA (plan-do-study-act) improvement cycle (Fig 2).
Key elements to successful implementation of the process modules are:
- Involve key stakeholders at each stage, for example, ward waitress, dietitian and speech therapist for meals module;
- Link to other hospital-wide projects, for example Essence of Care;
- Decide ‘what good looks like’ – consider local, trust and national guidelines, for example NICE guidance;
- Consider trust-wide training days to help staff implement change.
See Box 3 for tips on implementation.
Box 3. Tips on implementation
- Create an area or website on the hospital intranet for sharing information.
- Give plenty of advanced notice to wards so they can plan off duties to release staff for project work.
- Develop good communication links with estates departments as well as a mechanism to monitor the progress of Productive Ward estates jobs.
- Visit at least one other hospital doing Productive Ward before implementing it.
- Share information between wards and departments.
- Get to know other facilitators to form a network for mutual support.
- Agree how the hospital management will help solve problems that are outside ward control.
Our experience in supporting implementation of Productive Ward over the past 18 months has helped to demonstrate that effective change can happen and this can improve the experience of patients and staff on wards.
This tool has the ability to empower staff and improve services with a truly bottom-up approach. The way the project is implemented allows ward leaders and their teams to take a step back and look at how they work and what they can do to improve this.
This project undoubtedly reduces the amount of time ward staff spend doing tasks unrelated to patient care, for example looking for ward keys. It has greater benefits in helping to produce a cultural change in how wards use their specialist knowledge to improve the quality of their services for patients.
Bloodworth, K. (2009) Productive Ward 1: implementing the initiative across a large university teaching hospital. Nursing Times; 105: 24, 22-25.
NHS Institute for Innovation and Improvement (2007) Releasing Time to Care. Coventry: NHS Institute for Innovation and Improvement.