Chable, Rosemary

Griffiths, Peter

Maben, Jill

Robert, Glenn

Sarre, Sophie

English

Productive Ward: Releasing Time to Care™ was a large-scale nursing quality improvement programme introduced to English acute trusts a decade ago to improve productivity and reduce wastage on the ward. A multi-methods study looked at what remains of the programme today, how it was implemented and whether it has had any lasting impact. It concludes that it has useful lessons for the design, implementation and sustainability of other large-scale quality improvement programmes

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                       King’s Research Portal  Document VersionPublisher's PDF, also known as Version of recordLink to publication record in King's Research PortalCitation for published version (APA):Sarre, S., Robert, G., Maben, J., Griffiths, P., & Chable, R. (2020). Productive Ward: lessons from a quality-improvement programme. Nursing Times, 116(3).Citing this paperPlease note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this maydiffer from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination,volume/issue, and date of publication details. 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Oct. 2023Copyright EMAP Publishing 2020This article is not for distributionexcept for journal club use27Nursing Times [online] March 2020 / Vol 116 Issue 3 www.nursingtimes.netProductive Ward: Releasing Time to Care™ – one of the first national nursing quality-improvement interventions in NHS trusts in England – is now a decade old. Developed by the NHS Institute for Innovation and Improvement (NHSIII), and subsequently adopted outside the UK, the programme was based on lean princi-ples from manufacturing and designed to improve productivity and reduce the waste of time, movement, effort and stock on the ward. Comprising 11 modules and several tools (Fig 1) to empower ward staff to make local improvements, it aimed to: l	 	Increase the time nurses spend on direct patient care; l	 	Improve the safety and reliability of care; l	 	Improve the experiences of staff and patients; l	 	Make changes to the physical environment to improve efficiency (NHSIII, 2008). Productive Ward had three distinctive features:l	 	Its systematic, sophisticated design and development process – it was designed in collaboration with industry partners and developed incrementally through piloting and refining modules in NHS trusts;l	 	The high speed at which it was adopted – three months after its launch in January 2008, the government invested £50m to support its implementation. By March 2009, 36% (n=140) of trusts (acute and non-acute) had purchased a support package (Robert et al, 2011) and, by May 2012, it was reportedly being implemented by 70% of all UK acute wards (NHSIII, 2012). l	 	The bold claims made about its impact, both potential and achieved. Productive Ward 10 years onFrom 2016 until 2018, we conducted a study to investigate the legacy of Productive Keywords Quality improvement/Productive Ward/Research  This article has been  double-blind peer reviewedKey points Productive Ward, a nursing quality-improvement programme, was introduced into acute trusts in England 10 years ago It aimed to free up more time for patient care by improving productivity and reducing wasteOngoing use of Productive Ward has not been sustained but its impact on practices and quality-improvement strategies is still evident The experience of the programme has lessons regarding the design, implementation and sustainability of other large-scale quality-improvement programmes Trusts implemented the programme differently, affecting its assimilation into routine practice and, ultimately, its legacy and sustainability Productive Ward: lessons from a quality-improvement programme Authors Sophie Sarre is research fellow; Glenn Robert is professor of health care quality and innovation, both at Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London; Jill Maben is professor of health services research and nursing, University of Surrey; Peter Griffiths is professor of health services research, University of Southampton; Rosemary Chable is deputy director of nursing, education and workforce training, University Hospital Southampton NHS Foundation Trust.Abstract Productive Ward: Releasing Time to Care™ was a large-scale nursing quality- improvement programme introduced to English acute trusts a decade ago to improve productivity and reduce wastage on the ward. A multi-methods study looked at what remains of the programme today, how it was implemented and whether it has had any lasting impact. It concludes that it has useful lessons for the design, implementation and sustainability of other large-scale quality improvement programmes. Citation Sarre S et al (2020) Productive Ward: lessons for a quality-improvement programme. Nursing Times [online]; 116: 3, 27-29. In this article...l   What was Productive Ward and what was it designed to do?l   The legacy of Productive Ward 10 years onl   Lessons for other large-scale quality improvement programmesClinical PracticeResearchQuality improvementCopyright EMAP Publishing 2020This article is not for distributionexcept for journal club use28Nursing Times [online] March 2020 / Vol 116 Issue 3 www.nursingtimes.netnot to do it … If you didn’t do things that were perceived to be things that you should be doing, that always felt to be a bit risky… a risk that may not be worth taking.” As the study was retrospective, there was limited information on steps taken by trusts to assess readiness, but it is possible that, in the swell of enthusiasm, some steps were missed. The reputation of Productive Ward also suffered, to some degree, from extensive benefits being claimed without a strong evidence base. Many trusts, particularly later adopters, did not follow the detailed implementation guidance in the Produc-tive Ward toolkit and fidelity suffered over time. Wards often rushed through the 11 modules or simply missed some out alto-gether. Funding in larger organisations with more wards, although significant, was not available for long enough (typically two years) for Productive Ward teams to imple-ment the programme the way its designers had intended. This was increasingly evi-dent as they ran out of time, particularly as the most-challenging wards were typically left until last. As one Productive Ward lead at a case study site explained:“So what we did [with the Well Organised Ward module]… we gave them a day of our time …. The other [modules], like Knowing How we’re Doing and Patient Status at a Glance, [with] some of the wards it was … ‘This is a general introduction, what we’re going to do, and we need to change it’ and every once in a while, ‘Actually this has got to happen, we’re delivering a [‘Knowing How we’re Doing’ or ‘Patient Status at a Glance’] … some of the later wards we [just] dropped off the board.” Local ownershipEnsuring local ownership of the pro-gramme by empowering ward staff was an underpinning principle of Productive Ward and had previously been found to influence successful implementation at a local level (National Nursing Research Unit and NHSIII, 2010). However, our study showed that, over time, implementation often became facilitator-led rather than ward-led and, although there were reports of positive staff engagement, some wards failed to involve lower levels of ward staff in any meaningful way. In early-adopter sites, there was a noticeable shift over time: they moved FindingsOur survey received responses from 73 acute trusts (48% of trusts). Most directors of nursing reported that Productive Ward was no longer in regular use; the average length of use was three years since initial adoption. Half of trusts that had stopped using it said the reason was lack of resourcing, especially of Productive Ward leader time, and only six trusts still had a designated Productive Ward champion. Nonetheless, some wards con-tinued to use processes and practices arrived at through implementing Productive Ward (for example, display of metrics data, pro-tected mealtimes) and some still retained ward storage systems they developed as part of Productive Ward as a material legacy of the programme. One of the lasting impacts of Produc-tive Ward was the extent to which it still informed trust-wide quality-improvement strategies. Nearly half of directors of nursing said it had informed or been inte-grated into the quality-improvement strategy of their trust, which had given the trust a formal quality-improvement role for the first time.ImplementationProductive Ward guidance included steps to ensure the trust was ready to adopt the programme, but the expectation was that all acute hospitals should adopt it. As one director of nursing said:“[Productive Ward] fell into the category of things that … were being promoted … you get to a point where you almost have to have a good reason Ward a decade on, and whether it had achieved sustained impact. We examined the nature and extent of any impact, and how this was shaped by the way the pro-gramme was implemented and embedded into routine practice. Funded by the National Institute for Health Research’s Health Services and Delivery Research Programme, the study was led by King’s College London, which worked with researchers from the Univer-sity of Surrey, University of Southampton and University Hospital Southampton NHS Foundation Trust. It comprised:l	 	An online national survey of directors of nursing and Productive Ward programme leaders in acute trusts in England; l	 	Interviews with former Productive Ward leaders; l	 	Case studies of Productive Ward in six acute trusts. Case-study sites were chosen that had adopted Productive Ward at different times in its history, and captured a range of trust types and regions. At each site:l	 	Interviews were held with staff and (where these existed) patients who had been involved in Productive Ward;l	 	A questionnaire was distributed to the ward manager and wards were observed for legacies of Productive Ward on environments and processes; l	 	Routinely collected data was examined for Productive Ward-related outcomes.The final research study report – Sarre et al (2019) – is now available, and the findings and learning points are summarised here. Clinical PracticeResearchFig 1. Structure of the Productive Ward: Releasing Time to Care™ programme Source: NHS England Improvement Hub (england.nhs.uk/improvement-hub/productives).  ©NHS Institute for Innovation and Improvement 2008Patient hygieneThe Productive WardPatient observationsKnowing how we are doingWard leader’s guideProject leader’s guideExecutive leader’s guideAdmissions  and planned dischargeNursing procedures Ward roundWell-organised  wardShift handovers Meals MedicinesPatient status at a glanceToolkitCopyright EMAP Publishing 2020This article is not for distributionexcept for journal club use29Nursing Times [online] March 2020 / Vol 116 Issue 3 www.nursingtimes.netl The study was funded by the National Institute for Health Research’s Health Services and Delivery Research Programme (HS&DR - Project: 13/157/44). The views expressed in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, or the Department of Health and Social Care.ReferencesBatalden P (2018) Getting more health from healthcare: quality improvement must acknowledge patient coproduction—an essay by Paul Batalden. BMJ; 362: k3617. NHS Institute for Innovation and Improvement (2012) Response to a Freedom of Information Request FOI-108. Coventry: NIII.NHS Institute for Innovation and Improvement (2008) The Productive Ward: Releasing Time to Care. Knowing How We Are Doing Module Booklet Version 3. Coventry: NIII.National Nursing Research Unit and NHS Institute for Innovation and Improvement (2010)  The Productive Ward: Releasing Time to Care Learning and Impact Review – Final Report.  Bit.ly/NHSIIIProdWardImpactRobert G et al (2020) Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme in English acute hospitals. BMJ Quality & Safety; 29: 1, 31-40.Robert G et al (2011) The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: the Productive Ward in England. Journal of Clinical Nursing; 20: 7-8, 1196-1207.  Sarre S et al (2019) The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study. Health Services and Delivery Research; 7: 28.Shediac-Rizkallah MC, Bone LR (1998) Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Education Research; 13: 1, 87-108.introduced at ward level by Productive Ward were sustained only superficially; for instance, although data-visualisation boards were commonly found, they were often out of date and not regularly dis-cussed with ward teams. However, where ward staff had been given a real under-standing of the underlying principles of Productive Ward, they continued to apply them in new and innovative ways in response to changes on the ward.Involving service usersAlthough Productive Ward guidance sug-gested roles for patients, visitors and patient representatives at ward and hos-pital level, our study suggested that such involvement was generally low to non-existent. Recent interest in how coproduc-tion can underpin quality-improvement work holds important lessons for mean-ingful and imaginative ways in which ser-vice users can, and should, be part of designing and evaluating large-scale quality improvement programmes (Bat-alden, 2018).  SummaryOur investigation into the implementa-tion, assimilation, legacy and long-term impact of Productive Ward has useful les-sons for the design, implementation and sustainability of other large-scale quality-improvement programmes (Box 1). It shows that, while the programme’s ongoing use as a quality-improvement approach has not been sustained, its impact on ward practices is still evident and it has informed quality-improvement strategies in some trusts. NTaway from empowering ward staff to take ownership of the programme by enabling them to implement the modules them-selves and moved towards programme leaders and/or ward managers imposing ‘solutions’, as they focused more narrowly on the goals of Productive Ward and stand-ardising implementation throughout the trust. In sites that adopted Productive Ward at a later date, this limited view was more common from the start. Design and resourcingOne observed limitation of Productive Ward was that by focusing exclusively on ward and nursing processes, the original framing and format did not meet more-recent demands for multidisciplinary team working and whole-system transfor-mation. Trusts with strong cultures in terms of quality improvement or change management engaged central services at management level, which helped with implementation and broadened the poten-tial impact of the programme. Large-scale quality-improvement pro-grammes need to be sufficiently resourced not only to release ward staff to carry out task-driven activities (which were reported by staff as being beneficial in imple-menting Productive Ward) but also to allow experiential learning relating to the programme’s underlying principles. Having a dedicated member of staff to co-ordinate activities and training was key to achieving sustained impact.SustainabilitySome of the case-study sites lacked a clear sustainability plan, and a sustainability tool launched by NHSIII was criticised by some participants for measuring modules completed, rather than outcomes achieved and lessons learned. Robust measurement of impacts and costs (for a minimum of six months before and after implementation) and consistent data col-lection needed to be built in from the start, bearing in mind that the metrics valued by wards and organisations may be different.Shediac-Rizkallah and Bone (1998) argued that a programme’s sustainability should be judged on whether it has evolved and adapted, rather than having simply remained in place unaltered. At an organi-sational level, quality-improvement pro-grammes need to change and adapt so that learning and resources can be applied to new organisational or NHS priorities, rather than having to start again with new programmes. In many cases, measures For more articles  on hospital nursing, go to  nursingtimes.net/hospital-nursesClinical PracticeResearchBox 1. Lessons learned from Productive Ward for large-scale quality-improvement programmesl		Think beyond the ward – engage managers at an organisational level to help with implementation and broaden the impact of the programmel		Resource properly – ensure sufficient resources, including appointing a dedicated member of staff to coordinate activities and trainingl		Go for quality, not quantity – keep programmes slimline and focused so they are easier for staff to implement; empower frontline staff to take ownership rather than imposing ready-made solutions; and measure success in terms of learning and outcomes, rather than completion of the programmel		Build in sustainability and robust evaluation – draw up a sustainability plan and build in robust systems from the start to measure impacts and costs using metrics that are useful at both ward and trust level l		Adapt and change – at an organisational level, adapt the programme to meet changing needs and priorities, while ensuring staff at ward level have a clear understanding of the underlying principles so they can apply them in new or different ways as ward requirements and circumstances changel		Involve patients and carers – look for new, innovative ways to involve service users in design and evaluation

Productive Ward:lessons from a quality-improvement programme

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