A report published today assessing the impact of the ‘Productive Ward: Releasing Time to CareTM’ quality improvement programme, has found that whilst the intervention has left positive legacies a decade after its implementation, sustained impact was strongly influenced by how implementation was resourced and executed, and by the design of the programme itself.
The two-year study: ‘The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study’ was commissioned and funded by the National Institute for Health Research, Health Services and Delivery Research programme (NIHR HS&DR) and was conducted by researchers at King’s College London, University of Surrey, University of Southampton and University Hospital Southampton NHS Foundation Trust.
The ’Productive Ward: Releasing Time to CareTM’ programme was introduced by NHS Improvement in English acute hospitals 2007 with government funding of £50 million. This quality improvement intervention sought to help NHS staff to increase productivity and reduce waste, provide better quality, safer care and a better experience for patients and staff.
The focus of the programme was primarily on nurses, who – if working on a ‘productive ward’ - would, for example, streamline mealtime process, improve the reliability of patient observations and reduce the time they spent on fetching supplies, so they could spend more time with their patients. The programme consisted of modules (e.g. well organised ward, patient status at a glance, meals and medicines), a toolkit and guidance, which sought to enable frontline staff in acute hospitals to take ownership of their ward and improve the ways in which it worked.
The study surveyed the Directors of Nursing in all acute Trusts in England and staff that currently or recently lead Productive Ward at Trust level. Interviews were also conducted with former Productive Ward leads. There were organisational case studies within six acute Trusts, which involved interviews with those involved in implementing Productive Ward; structured observations and questionnaires to ward managers on two wards at each hospital; and analysis of reports and outcome measures.
The study explored the timing of adoption, how Productive Ward was implemented, reported impacts, what happened to the programme over time, what legacies remained and what factors had helped or hindered sustainability.
The main findings and implications include:
- There were significant variations in implementation that had important consequences for the sustainability of the programme over a decade. For example, over time it was less common to train and involve whole ward teams. Instead Productive Ward leaders and ward managers tended to execute ‘short cuts’ motivated by time constraints and a trust-level desire for standardisation.
- During implementation Productive Ward was seen to have led to positive change through more efficient and/or standardised routines; the display of information; rethinking processes; giving staff a voice; and improving staff knowledge and skills in quality improvement.
- In all case study sites, material legacies (e.g. display of metrics data; storage systems) and some ward practices remained. However, in practice these did not always serve their original purpose well. For instance, safety incident and other ward-level data were not always up to date or on public display; and were often difficult to interpret, and rarely discussed with whole ward teams.
- A significant proportion of trusts reported regularly using some elements of Productive Ward, and said it informed wider organisational quality improvement strategies that remain in place today.
- Whilst evidence from the survey showed that Productive Ward was overwhelmingly viewed as positive, for some specific aims (e.g. staff morale) a relatively high proportion of respondents noted no impact.
- Only one Trust had robust outcome data over time. This showed a modest improvement in time nurses spent directly caring for patients as wards progressed through the Productive Ward modules.
- NHS England plans to refresh and relaunch Productive Ward. In collaboration with NHS England, the research team have developed a set of recommendations based on their findings to help guide this national relaunch. Given the limitations of the existing evidence base, the researchers caution against a sole focus on the intervention’s potential for productivity improvements and efficiency savings. Rather, highlighting how staff and patient experience might be improved through implementation of a modified form of the Productive Ward is likely to be more engaging and - combined with more targeted and rigorous data collection - lead to a clearer business case for the programme. Any future similar programme should avoid a purely nursing focus and recognise the multi-disciplinary and whole hospital nature of contemporary service delivery. A focus on the three core modules and a much smaller number of process modules would facilitate implementation and sustainability in increasingly busy ward environments.
"There is no doubt that with few exceptions, people who had been meaningfully involved in implementing Productive Ward were enthusiastic about its potential to release time to care. Key to sustainability were having the resources to engage and provide training to staff of all levels and disciplines in and beyond the ward. This instilled a Productive Ward mindset that meant that staff could continue to make improvements as contexts changed over time. A leaner programme would help sustainability."– Dr Sophie Sarre, Lead Author