Productive Mental Health Ward aims to reduce waste and free up time for direct care. A trust discusses the impact of the initiative on both patients and staff
Mary Mumvuri, RMN, MSc Health Management, MSc Mental Health Studies, is assistant director of Nursing – Achieving Quality Improvement Programme (AQUIP); Amanda Pithouse, RMN, is productive services coordinator; both at South London and Maudsley NHS Foundation Trust.
Mumvuri M, Pithouse A (2010) Implementing and evaluating the Productive Ward initiative in a mental health trust. Nursing Times; 106: 41, early online publication.
The aim of this article is to reflect and share the experience of implementing Productive Mental Health Wards (PMHWs) at South London and Maudsley NHS Foundation Trust. It highlights the processes involved and the outcomes. It also discusses the challenges encountered, the strategies employed to overcome them and subsequent changes to practice.
Keywords Mental health, Direct care time, Productive ward
- This article has been double-blind peer reviewed
- The Productive Mental Health Ward was developed by the NHS Institute for Innovation and Improvement to help staff redesign the way they work so they can spend more time with service users in direct care.
- “Showcase” wards are pivotal to preparing to implement PMHW, as they provide opportunities for others to see how the initiative works in practice and its potential impact.
- Ward teams, with input from carers, services users and improvement facilitators, need to develop a shared vision of what they want their ward to look and feel like.
- Audit visits conducted by senior leaders and managers from across the trust help to bridge the gap between the board and the ward by making them more visible. These visits allow senior staff to hear firsthand experiences of delivering and receiving care on the ward.
The Productive Mental Health Ward (PMHW) initiative has focused attention on inpatient nursing care. It empowers front line staff to improve the quality of care they deliver by using systematic processes and tools to change practice. The scheme has started to show a positive impact on staff well being, safety and reliability of care, patient experience and efficiency of care - the key areas identified for improvement within the initiative (NHS Institute for Innovation and Improvement, 2008.
PMHW is a modular based, self directed quality improvement initiative that teaches staff how to assess and redesign the way they work. The aim is to reduce waste in relation to time and costs inherent in ward systems and care delivery processes, which will lead to a better experience for service users and carers and to better clinical outcomes.
While the initiative is aligned nationally to the quality agenda – as described in High Quality for All: NHS Next stage review (Department of Health 2008) - within the trust it is a key component of the Achieving Quality Improvement Programme (AQUIP). It has been used as a vehicle for delivering improvements across inpatient services and in embedding some of the internal and external quality assurance standards, such as those from the Royal College of Psychiatrists’ College Centre for Quality Improvement (2006) Accreditation for Inpatient Mental Health Services (AIMS), as well as other initiatives such as Star Wards (Bright, 2006).
Background to PMWH
Evans (2007) identified that nurses reported spending about 40% of their time on direct patient care, which was less than their aspiration of more than 60%. Staff said that lack of time spent in direct care time had an adverse impact on patient care and job satisfaction.
PMHWs was developed by the NHS Institute for Innovation and Improvement, and launched nationally towards the end of 2008 (NHS Institute for Innovation and Improvement, 2008). It is part of the “Productive” series that includes initiatives such as “Productive Community Services” and “Productive Wards”. These were developed to help staff redesign the way they work so they can spend more time with service users in direct care.
While some work has been published by Bloodworth K (2009) and by Foster and Gordon (2009) on how the initiative was rolled out across an acute hospital, there is limited published work on the experience of mental health organisations.
Similar to other Productive series, PMHWs focuses on “how to do”, rather than “what to do”. It consists of three foundation modules and eight process modules. The foundation modules are designed to help teams understand their performance by using routinely gathered performance data or developing systems to capture information that impacts on the team’s functioning. Built into the tools and methods are some Lean principles and tools.
Other key aspects of the foundation modules include organising the ward environment so information and equipment are visible, easily accessible and available in the right quantities at the right time for the right people. Teams have to complete the foundation modules before proceeding to process modules. Fig 1 shows all the modules contained in the PMHW “house”.
Preparation for implementing the initiative
This involved teams of multidisciplinary staff at different levels, as well as representatives from finance and the trust executive, visiting an acute and mental health trust to hear about practical application of PMHW, the process for trust wide roll out, and the benefits and challenges. They also learned about resourcesimplications, the level of commitment needed and the difference PMHWs had made to practice.
Prior to implementing the initiative, it was prudent to review it to ensure it was aligned to existing quality improvement programmes in the trust and to the trust’s values and objectives. The Trust Service Quality Executive - the internal committee that has a remit for approving quality initiatives - also needed to approve the scheme. As soon as a strategic fit was established and the visits were completed, a communication and detailed project plan was developed that included a six monthly roll out plan over three years.
A pivotal part of the preparatory work was the selection of “show case wards”. These were wards where staff were willing to participate in the project, share their knowledge and experiences, and provide opportunities for others to see the practical application of PMHWs and its potential impact. The wards needed to satisfy a selection criteria set by the project team, which included such factors as having a ward leader in post and having less than 10% vacancies.
All 65 ward leaders were invited to apply. Following the short listing process, six wards were selected to be showcase wards. These represented different clinical services, such as acute adult psychiatry, older people, forensic and rehabilitation and a national behavioural disorders unit, which were located across five sites. The ward leaders included an occupational therapist, which demonstrated that the initiative was not only relevant to nurses.
A project bid was submitted to NHS London and the trust was awarded some funding to support the start up of PMHWs on six wards for the first nine months – after which funding was provided by the trust board. The funding enabled the project team to employ two full time improvement facilitators, purchase resources required and set aside money for anticipated minor works when it came to reorganising the ward environments.
Once the showcase wards were selected, the project team conducted briefing meetings for the staff involved to discuss their roles and responsibilities and the team could try to alleviate any anxieties. During these meetings, the ward teams were informed about the support that would be available to them, as well as the benefits to them. A webpage was set up on the trust intranet with information and resources’ relating to the project and information leaflets for service users, carers and staff were developed.
The NHS Institute initially provided training and support for ward leaders, improvement facilitators and the project lead. The training covered the foundation modules and one process module. Subsequent training to support roll out has now been developed and is delivered by the project team.
Implementing the modules
Our trust’s experience has been that it takes between three to four months to complete the foundation modules. The time it takes to complete a process depends on the unique features of each team but has ranged from between two and six months. Ward teams are supported by improvement facilitators up until they complete all the foundation modules and the first process modules.
The first action for each ward team with input from carers, services users and its facilitator was to develop a shared vision of what they wanted their ward to look and feel like. A variety of methods were used to capture all the views to ensure inclusivity. The agreed vision was then displayed in prominent places on the ward and reviewed periodically. The result of this work showed there were common themes shared by service users, carers and staff, but they had never been discussed before.
Knowing How We are Doing
This module focused on identifying and selecting ward based measures to help teams’ understanding of their performance on key objectives and to set actions for improvements. Table 1 shows the measures used to address the objectives.
Staff found the process of selecting and monitoring measures at ward level empowering. The performance data was displayed in a communal area for anyone visiting the ward to see. The information displayed on the board formed the basis for discussions and reviews at PMHWs weekly meetings, and where possible involved service users. The discussions around the board encouraged openness, an acknowledgement of weaknesses and highlighted what the team was doing to address any problems. It helped give a sense of shared responsibility between the service users and staff members to ensure improvements were made.
A key feature of this module was the “activity follows”. This involved a ward staff member following another member of staff at a similar grade with a similar professional background, noting what they were doing every minute for 12 hours. When analysed, the activity data showed the proportion of time spend on direct care which is referred to as “direct care time” and that spent on non-patient related activities, and the number of interruptions to intended tasks. This information provided an indicator of the process modules that the teams needed to focus on to increase their direct care time and to reduce the type of associated interruptions to care delivery.
Well Organised Ward
This module generated immense energy from the team members because of its practical approach, the immediacy of improvements and the use of visual management techniques. It uses a variety of Lean tools to make information, resources and equipment easily visible, accessible and organised, which reduces time wasted looking for things, as well as cutting costs associated with over ordering items that might expire before use. Teams have been able to develop inventories for stock items and to create systems for replenishing these in an efficient manner. Following the WOW module, there was an average cost saving of £1,500 per ward from unused items in the ward store rooms.
Patient Status at a Glance
The focus of this module was on developing patient status information boards to improve communication between team members, reduce patient status related interruptions to care, and show at a glance risk issues related to mental state and physical health. Not all wards in the showcase group used white boards to display patient information, so this was a challenge for those teams. Confidentiality issues were discussed with service users where appropriate and advice was also sought from the trust Caldecott guardian in reaching agreeable solutions. Relevant standards were set for updating and monitoring the efficiency of the PSG boards through audits. Feedback from teams indicated that it was now easier to know the whereabouts of service users, leave status and levels of observations and that it was quicker to access information that would normally be held electronically. Frequency of interruptions also reduced significantly.
Following the implementation of the foundation modules, the teams selected process modules to implement based on the information from the “activity follows” and foundation modules. The most popular process modules were shift handovers, medicines, ward round, safe and supportive observations and therapeutic engagement. Quantitative data on process modules is still being analysed for impact.
During the initial stages of the initiative most of the benefits were qualitative, however some quantitative benefits have been emerging.
Improvement in efficiency of care: direct care time
Direct care time has been variable across all the participating wards and has ranged from 11% to 48% at baseline, to about 41% to 84% after eighteen months, resulting in an average increase of 24% in eighteen months. Feedback from the service users survey indicate an increase of up to 50% in therapeutic time spent with a named nurse and a 40% increase in activities provides on the ward. Table 2 shows the direct care time for a group of wards. The data are for individual wards recorded at six month intervals.
The strengths of this initiative are that the focus is not only on service users and carers, but also on the well being of staff. Monitoring staff stress allowed ward leaders to respond to those individuals who might be stressed at work. As one service user said on one of the showcase wards, “happy staff makes a happy and productive ward”. Fig 2 shows the sickness absence for the showcase wards.
Reduction in violence and aggression
The initiative is making an impact on violence and aggression. There has been a 50% reduction in violence and aggression on two participating acute wards.
Fig 3 shows a reduction of violence and aggression for the showcase wards over a period of a year.
Valuing and empowering staff
Some staff said they feel more valued by managers and leaders. They also talk of the value of learning new skills, of having leadership development at all levels within the team and a sense they can bring about change and improve quality. The bottom up approach is regarded as having empowered staff to take ownership of problems with their systems and processes, rather than being told what to do.
Bridging board to ward gap
The audit visits, which are conducted by senior leaders and managers from across the trust, provided an opportunity for them to “walk the floor” which helped to bridge the gap between the board and the ward. It made leaders and managers more visible and they were able to hear firsthand the staff experience of delivering care and the patient experience of receiving care on the ward and to deal with issues affecting the implementation of modules.
As with any management of change, there are challenges to implementing this initiative.
The biggest challenge is sustaining improvements in the context of constant organisational changes and competing demands. The vision of the trust is that PMHW should not be seen as yet another service improvement initiative that will run its course, but rather that it becomes a way of working that is firmly embedded into the practice.
Approaches being used to ensure sustainability include:
- NHS Institute for Innovation and Improvement sustainability model;
- Regular audit visits by senior leaders;
- Attendance at project implementation team meetings and project board meetings. The Project Board is chaired by the Chief Executive and attended by the Executive Director of Nursing and representatives from across clinical services;
- Ward audits of standards set in each module;
- Brief periods of focused intensive support from improvement facilitators;
- Communication from the project team and trust that the initiative is a way of working rather than a project with a start and end date.
Working on multiple sites
The trust is spread across a wide geographical area that can be difficult to get around, however sound planning skills and mobile working using laptops has reduced unnecessary travelling back to the office to complete administrative work. It has also been a challenge to get teams together for project implementation meetings, but rotating venues has helped with sharing practice, showcasing achievements and having a better insight into work being carried out in other clinical services.
Data collection and analysis
Despite systems and processes being set up for collecting and submitting ward performance data, this remains a challenge for ward teams to achieve in a timely manner. The improvement facilitators still have to chase teams for their monthly data that feeds into the overall project data. In response to this, further training has been offered to ward administrators on the data requirements for the project because they have a key role in gathering other data for the wards and this is beginning to make a difference. Teams are also encouraged to use the resources of team members who are more confident with using software packages.
An evaluation commissioned by NHS London and conducted by Deloitte in March 2009, identified several key ingredients to the successful implementation of the PMHW initiative. These included the robust governance arrangements that were set up, the support the scheme received from senior managers and leaders within the trust and the emphasis and commitment to a bottom up approach. Collaborative working towards quality improvement, the resources allocated and the training and coaching of ward teams by the improvement facilitators have also helped to ensure the scheme was able to benefit both patients and staff.
Bloodworth K (2009) Productive Ward 1: Implementing the initiative across a large university teaching hospital. Nursing Times; 105: 24, 22-25.
Bright (2006) Star Wards
Department of Health (2008) High Quality for All: NHS Next Stage Review Final Report. London: DH.
Evans R (2007) Releasing Time to Care: Productive Ward survey results. Nursing Times; 103:16, (supplement) s6-s9.
Foster S, Gordon P ( 2009) Rolling out Productive Ward foundation modules across a hospital trust. Nursing Times; 105: 30, 28-30.
NHS Institute for Innovation and Improvement (2007) Releasing Time to Care: Productive Ward. Coventry: NHS Institute for Innovation and Improvement.
NHS Institute for Innovation and Improvement (2008) Releasing Time to Care: Productive Mental Health Ward. Coventry: NHS Institute for Innovation and Improvement.
Royal College of Psychiatrist’s College Centre for Quality Improvement (2006) Accreditation for InpatientMental Health Services (AIMS).