Implementing three foundation Productive Ward modules resulted in increased time for care, reduced infection rates and decreases in non-pay expenditure
Sam Foster, MSc, BSc, RGN, was head of nursing; Pete Gordon, RGN, ENB 100, is head of continuous improvement; both at The Shrewsbury and Telford Hospitals NHS Trust; Wilfred McSherry, PhD, MPhil, PGCE (FE), PGCRM, BSc, RGN, NT, ILTM, is professor in dignity of care for older people, Centre for Practice and Service Improvement, Faculty of Health, Staffordshire University. Sam Foster is now deputy chief nurse at Heart of England NHS Foundation Trust.
Foster, S. et al (2009) Rolling out Productive Ward foundation modules across a hospital trust. Nursing Times; 105: 30, early online publication.
The Shrewsbury and Telford Hospitals NHS Trust has spent the last 12 months rolling out the Productive Ward foundation modules across the whole organisation. This has resulted in measurable increases in time spent on direct care, and reduced infection rates and ward non-pay (non-staffing) expenditure. This article discusses the initiative and looks at how problems with the hospital supply chain are being addressed.
Keywords: Productive Ward, Service improvement, Quality of care
- This article has been double-blind peer-reviewed
Releasing Time to Care: the Productive Ward was developed by the NHS Institute for Innovation and Improvement (2007).
This innovative and practical programme of work aims to help ward teams make time for patient care by using improvement skills to review the ward environment and ward processes. It is a systematic and inclusive approach to improving the reliability, safety and efficiency of the care that all nurses deliver.
The Shrewsbury and Telford Hospitals NHS Trust joined the Productive Ward programme in 2007 as the West Midlands Strategic Health Authority (SHA) learning partner, to act as a pilot site for its implementation before national roll-out.
The selection criteria required the partner to demonstrate how Productive Ward was aligned to organisational strategic objectives. Support from the trust board was essential as this was deemed to be a key factor for success.
Productive Ward’s aims are to:
- Increase direct time for patient care;
- Improve patient and staff experience;
- Improve patient safety.
The programme achieves the above aims by creating a strong focus on the processes of care within the ward setting. In our experience, it significantly increases the proportion of time nurses spend on providing direct care to patients.
Approach to implementation
A number of approaches to Productive Ward implementation were explored and we identified that it was necessary to put the programme into the context of the trust’s needs.
A full-time project manager was appointed to ensure the roll-out would be coordinated and the changes sustainable.
It was decided to take the unusual approach of implementing the three foundation modules across the whole organisation and then moving on to other modules (see Box 1).
The trust communications team ensures that all members of staff are aware of the programme.
Box 1. Three core modules
- Knowing How We Are Doing
- Well Organised Ward
- Patient Status at a Glance
Well Organised Ward module
The first step was to implement the Well Organised Ward module, which focuses on making the ward areas work for nursing staff. For example, everything should be in its correct place and where staff expect it to be. This means time is not wasted hunting down or locating the correct equipment or right medicines.
Every ward within the trust has had an introductory day to the Productive Ward programme and an intense two-day rapid improvement event involving 6-8 members of the ward team.
The rapid improvement event is a planned, intensive effort by frontline nurses to decide and implement environmental improvements, with the support of key professional groups such as porters and estates.
After the rapid improvement events, maintaining the momentum and sustaining the changes are a key focus for the ward, management and executive team.
The estates group was invaluable during the rapid improvement events. Money was allocated to the estates department to ensure ward staff have an estates officer with them at all times to move shelves, paint walls and do jobs as and when needed.
Staff who previously felt they had to wait months for basic ward improvements were delighted when they were able to make on-the- spot changes while undertaking improvement techniques highlighted in WellOrganisedWard activities.
Staff have commented: ‘If only it were this easy to get things done normally. We could stop working around problems and solve them quickly.’
It is noticeable that staff felt encouraged and empowered to solve their own problems.
After rolling out the foundation modules, direct care time has increased by 12-15% and time spent in motion - that is, time previously spent walking to collect equipment for procedures, put stock away or find equipment - has reduced by 10%.
Knowing How We Are Doing module
Two years before Productive Ward, the trust had developed a ‘nurse performance indicator’ (NPI) web-based tool. This tool uses a quality safety dashboard display to illustrate metrics with the view that any member of staff can understand the information within three seconds. Tailor-made notice boards on every ward display standardised ward metrics and these are clearly linked into the organisation’s corporate objectives. These are visible to staff, patients and visitors and emphasise the trust’s commitment to service improvement.
The Knowing How We Are Doing module has helped to make this information visible for the public within the wards. This has proved to be incredibly powerful when setting off on the path of service improvement at ward level.
The focus on the ward environment while implementing Well Organised Ward, combined with a greater emphasis on Knowing How We Are Doing, has contributed towards the significant decrease in healthcare-associated infections. The Productive Ward has encouraged staff to think about how they can overcome infection prevention and control issues. There has been an overall reduction in infection rates in the trust, presented in Fig 1.
Patient Status at a Glance
The final foundation module to be rolled out was Patient Status at a Glance. We had identified as part of the project that nurses are interrupted, on average, once every five minutes. Most of these interruptions were from multi-professional team members and relatives, who were looking for information about the location or discharge status of a patient.
Patient Status at a Glance aims to make information on a patient’s status clear to those who need it using visual tools. The aims were to provide up-to-date information that could be interpreted at a glance and used effectively. We held two workshops with a company called CY Health and ward leaders to pilot SMART board technology to develop the Patient Status at a Glance boards.
This is currently being piloted on the four fast-track wards with a view to interfacing it to the trust PAS system. The aim is to visually display patients’ journeys and reduce the number of times staff are interrupted – thus releasing time to care.
Supply chain to the Well Organised Ward
During implementation of the Well Organised Ward module it became apparent there were significant opportunities to improve the supply chain process to the wards. It was notable that non-pay expenditure decreased significantly after each ward’s rapid improvement event, following simple improvements to the ward layout. This was because wards were not over-stocked and it was easy for staff to find what they needed.
The reduction in non-pay expenditure for one ward is shown in Fig 2.
However, some problems with supplies continued, resulting in valuable nursing time being diverted away from delivering direct patient care. Common problems reported with the supply of stock to wards included:
- Stock not being available when a member of the ward team needed them;
- Ward staff spending significant amounts of time chasing stock or borrowing from other wards;
- Once-weekly deliveries being insufficient.
During discussions with ward staff, it became apparent they felt the process should be similar to going to the supermarket - staff on the ward are the customer and every time they need an item it should be there.
Based on this ‘supermarket’ principle, staff also began to question why there was only one delivery a week to the wards. They felt that increased deliveries would improve reliability as ward stock usage can fluctuate significantly within a matter of days if patient dependency increases.
The first step was to map the current supply chain process, noting value- and non value-adding elements. Ninety-five per cent of the process between the order being placed and the item being put in the correct place on the ward involved non-value adding activity for example, waiting. Additionally, a stock-take revealed that although there was enough stock in the hospital, staff were experiencing problems as the stock was not in the right place at the right time.
The trust is about to start a pilot project involving rapid replenishment of stock to the wards, based on actual demand. Minimum and maximum levels have been established by examining current usage information. Clear visual management systems will be in place in wards so supplies staff can see at a glance the number of items which need to be reordered.
Expected results include:
- Elimination of ‘out of stock’;
- Ward staff time freed up to deliver direct patient care;
- Reduction in non-pay expenditure.
Following the rollout of the three foundation modules to all ward areas, the trust now plans to fast-track four wards through all of the process modules, with concentrated support from the continuous improvement team. The trust continues to share and learn from experiences gained through the Productive Ward rollout programme across the West Midlands and nationally.
The trust is keen to evaluate the programme’s implementation and has been successful in obtaining a Higher Education Innovation Fund bid to work with Staffordshire University Faculty of Health. The plan is to establish a Knowledge and Transfer Partnership to ensure the findings from the Productive Ward inform programmes of nursing within higher education.
There is a strong commitment to sustainability supported by ongoing visits by the executive team and trust chair who visit wards to ensure momentum is maintained.
West Midlands SHA has played a key role in ensuring successful implementation of the Productive Ward. The trust’s executive team has fully supported the programme. The approach taken by Shrewsbury and Telford Hospital NHS Trust has resulted in remarkable benefits for patients and their families. The evidence emerging indicates that the Productive Ward has real benefit, and the entire programme is more than just a tidying exercise for nurses as it actually has significant impact on releasing time to care.
- The Productive Ward programme focuses on the process of care on wards.
- It significantly increases the proportion of time nurses spend on providing direct care to patients.
- It achieves this by improving the organisation of the ward and communication between staff, patients and visitors.
- Technology such as smart boards can be used to improve communication.
- The programme has led to a review of the way stock is supplied to wards.
- Nursing staff spend 40% of their time delivering direct patient care (O’Dowd, 2007).
- A poll of over 2,100 NHS staff found that nearly three out of four ward nurses felt they did not have enough time to care (Nolan, 2007).
- The vast majority – 90% – indicated that patient care suffered because of this lack of time to care.
NHS Institute for Innovation and Improvement (2007) Releasing Time to Care: The Productive Ward. Coventry: NHS Institute for Innovation and Improvement.
Nolan, A. (2007) Word on the wards. Health Service Journal; 117: (suppl), 3–6.
O’Dowd, A. (2007) Is patient care paying the price? Health Service Journal; 117: (Suppl), 7–9.