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Implementing and sustaining change in the contemporary NHS: lessons from the Productive Ward

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The National Nursing Research Unit has reviewed the spread of innovations in the NHS and their sustainability

Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one organisation, their systematic spread and sustainability is unpredictable (Berwick 2003.)  Given the quality and cost challenge currently facing the NHS, it is critical that improvement programmes are implemented quickly, on a large-scale and assimilated and sustained in routine practice. The National Nursing Research Unit (NNRU) reviewed the theory on the spread of innovations and applied this evidence to their ongoing research into the implementation and assimilation of the Productive Ward.  Here we present the findings and consider the implications for policy and practice.

The Productive Ward innovation

The Productive Ward has the potential to be adopted throughout the NHS at a scale and pace sufficient to achieve significant quality and productivity benefits (Department of Health, 2003). The programme seeks to increase the proportion of time nurses spend in direct patient care, improve experience for staff and patients, and make structural changes to the use of ward spaces to improve efficiency in terms of time, effort and money. The programme has been rapidly adopted by the NHS; approximately 85% of NHS acute hospitals have downloaded Productive Ward materials and - by March 2009 - 40% (140) of all NHS hospitals had purchased a support package, albeit with large variation between geographical regions (NNRU, 2011). However whilst some organisations have achieved 100% ward implementation others have just a few wards actively implementing the programme. The average proportion of wards in each organisation that are using The Productive Ward is estimated to be 35%. (NHS Institute for Innovation & Improvement)

The NNRU case study research in eight NHS trusts involved interviews with 38 individuals involved in implementing the Productive Ward Programme. Findings indicate what hinders and what helps the spread of the Productive Ward and how progress is being made in the current environment.

What hinders the spread of the Productive Ward?

Our research identified three particular processes which adversely affect the spread and sustainability of the productive ward: 

  1.  Discontinuation (halting Productive Ward work) does not commonly occur through explicit decisions made at executive level to formally ‘stop’ but rather through differing perceptions of what the Productive Ward is seeking to achieve amongst frontline staff. There is evidence to suggest that ward staff can sometimes view the Productive Ward as a time-limited project to be completed as quickly as possible rather than as an ongoing way of working (albeit one that encourages local adaptations and customisations of the Productive Ward modules). The evidence did suggest that sometimes the decision to temporarily halt implementation can be beneficial for ensuring the work is picked up at a defined time in the future, rather than struggling on while organisational energy wanes and contextual issues escalate. However assessment of progression requires agreed end points to implementation or completion of the programme.
  2.  ‘Islands of improvement’ occur because of only isolated uptake of the Productive Ward within an organisation. There is strong research evidence to suggest that improvements as a result of the Productive Ward often remain unknown to senior staff and other wards/departments. Whilst some ward teams learn about, implement and see the benefits of the programme, others working alongside them are unaware of the nature of the work going on.
  3.  Improvement ‘evaporation’ can occur through the loss of staff commitment to continuing to implement the Productive Ward. The research suggests that this was often the result of staff feeling their organisation no longer valued and supported the Productive Ward work as well as problems with the timing, pacing and flow of available support.


What facilitates the spread of the Productive Ward?

The evidence from this research suggests, firstly  that organisational energy for programmes such as the Productive Ward is determined by levels of visible executive support, resources for programme leadership and facilitation, and building resilience to times of pressure and change. Continuity of organisational energy helps to avoid discontinuation. Sometimes the decision to temporarily halt implementation can be beneficial for ensuring the work is picked up at a defined time in the future, rather than struggling on while organisational energy wanes and contextual issues escalate. 

Secondly, staff energy drives programme spread, but staff need to know about the programme, feel they are backed by organisational energy and have time and space to participate in ways that are meaningful and beneficial to them. In implementing organisations there will naturally be islands of improvement because of patterns of staff energy and approaches to implementation.

Thirdly, communication is essential to spread of the programme and the improvements made. It involves promoting the programme through existing structures such as induction programmes, education and training; maintaining interest on wards using informal interactions and reflection time; and linking monitoring and reporting into organisation-wide improvement meetings.

By being aware of these, those leading Productive Ward work elsewhere (and other similar improvement programmes) can plan to avoid the same processes slowing spread and undermining sustained change in their organisations by, for example, channelling resources and energies into areas where they will have the greatest impact.

Conclusions and implications

This research has led to a set of hypotheses about the spread of large-scale change that can be tested in future change interventions. This could help policy makers to move from a reactive to a more proactive understanding of the spread of large-scale change. 

  1. Successful implementing organisations invest energy in programmes by providing visible executive support, allocate resources for programme leadership and facilitation, and build resilience to times of pressure and change – continuity of these factors is essential.
  2. Programme leads play a vital role as boundary spanners (individuals who carry knowledge between different professional groups). They need skills not only in communicating vision and goals, but also the ability to encourage staff to take on leadership and management of the work.
  3. Spreading and sustaining programmes at ward-level involves harnessing staff energy in a mutually beneficial collaboration. Helping ward leaders to manage time and resources to release staff, supporting shared learning through local standardisation of materials (guidelines, notice boards, documents etc.) and procedures (where things can be found, how things are to be done, what things are called), inter-ward visits, and ward-to-ward communication are important.


Key issues for policy

In order for health care innovations to be sustained and spread policy makers need to consider:

  • Clearly connecting innovations in health care services and delivery with the political and social agendas facing NHS organisations;
  • Identifying and understanding the differing needs and characteristics of staff at organisational and service levels who are both key in supporting and sustaining innovation;
  • Supporting the continued engagement of relevant staff and respected individuals to ensure the spread and sustainability of any innovation;
  • Providing clear information about the (i) benefits of the innovation and (ii) its operational attributes;
  • Highlighting the importance of differing organisational contexts in shaping the success of an innovation, and leaving room for local adaptation in implementation as a “one size fits all” approach will not work.

A checklist designed in the course of the NNRU research to help those leading on the Productive Ward, provides a guide for local action for those seeking to maintain the momentum of innovations.

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