Project

Evaluating the ten year impact of the Productive Ward at the clinical microsystem level in English acute trusts

Goal: Clinical microsystems' - and how well they work - are the focus of this call for research proposals. A clinical microsystem can be any health care team providing services to patients, for example, a General Practice, a hospital ward or a clinical unit. This proposal is to find out whether a way of trying to improve how staff in hospital wards work - called the 'Productive Ward' - has been successful in NHS acute hospitals in England and to help managers, doctors and nurses who are continuing to use the approach to make it as useful as possible. The Productive Ward aims to allow nurses on wards to change the way they work so that they are more efficient by reducing waste and stopping nurses from spending time on activities that do not benefit their patients. The Productive Ward was first tried in the NHS in 2007 and in the 8 years that have followed most hospitals in England have used this approach as a way of making some or all of their wards work better. Although the NHS has spent significant amounts of money on using the Productive Ward (over £50 million) still little is known about whether it has worked or not or what its effect has been on patients and carers. Nor do we know whether hospitals that began to use it in 2007 have seen any benefits last. The research team previously studied how the Productive Ward spread through the NHS and have a list of all the 102 hospitals that had began using it by 2009. The researchers now plan to find out whether the wards in those hospitals are working better now than wards that either started to use the Productive Ward at a later date or who have not used the Productive Ward at all. The researchers will survey all 160 NHS acute hospitals in England to update their earlier study and find out whether they are currently, or have previously, used the Productive Ward and, if they have, the way in which they have used it and whether it has worked well. From the results of the survey the researchers will identify 3 hospitals that began to use the Productive Ward first and 3 that started later. The researchers will then carry out research in 2 wards in each of these 6 hospitals. The researchers will interview staff and patients in the hospitals to find out whether using the Productive Ward has brought about any benefits, such as whether nurses spend less time looking for equipment and other unproductive activities that the Productive Ward was supposed to reduce. The researchers will also try to find out whether there have been other benefits of using the Productive Ward, such as developing nurse leaders and whether different ways of introducing the approach have had any impact on the success or otherwise of the Productive Ward. Finding this out will help managers, doctors and nurses and other clinical staff in other hospitals think about how they are using the approach and whether they should do things differently in order to maximise it's impact. The research will take 30 months to finish and will answer whether using the Productive Ward over a 10 year period (2008-17) has made wards in English NHS hospitals more efficient, with less time wasted by nursing staff on activities that do not benefit their patients whilst also improving staff experiences too.

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Project log

Rosemary Chable
added a research item
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.
Glenn Robert
added 2 research items
Background The ‘Productive Ward: Releasing Time to Care’™ programme (Productive Ward; PW) was introduced in English NHS acute hospitals in 2007 to give ward staff the tools, skills and time needed to implement local improvements to (1) increase the time nurses spend on direct patient care, (2) improve the safety and reliability of care, (3) improve staff and patient experience and (4) make structural changes on wards to improve efficiency. Evidence of whether or not these goals were met and sustained is very limited. Objective To explore if PW had a sustained impact over the past decade. Design Multiple methods, comprising two online national surveys, six acute trust case studies (including a secondary analysis of local audit data) and telephone interviews. Data sources Surveys of 56 directors of nursing and 35 current PW leads; 88 staff and patient and public involvement representative interviews; 10 ward manager questionnaires; structured observations of 12 randomly selected wards and documentary analysis in case studies; and 14 telephone interviews with former PW leads. Results Trusts typically adopted PW in 2008–9 on their wards using a phased implementation approach. The average length of PW use was 3 years (range < 1 to 7 years). Financial and management support for PW has disappeared in the majority of trusts. The most commonly cited reason for PW’s cessation was a change in quality improvement (QI) approach. Nonetheless, PW has influenced wider QI strategies in around half of the trusts. Around one-third of trusts had impact data relating specifically to PW; the same proportion did not. Early adopters of PW had access to more resources for supporting implementation. Some elements of local implementation strategies were common. However, there were variations that had consequences for the assimilation of PW into routine practice and, subsequently, for the legacies and sustainability of the programme. In all case study sites, material legacies (e.g. display of metrics data; storage systems) remained, as did some processes (e.g. protected mealtimes). Only one case study site had sufficiently robust data collection systems to allow an objective assessment of PW’s impact; in that site, care processes had improved initially (in terms of patient observations and direct care time). Experience of leading PW had benefited the careers of the majority of interviewees. Starting with little or no QI experience, many went on to work on other initiatives within their trusts, or to work in QI at regional or national level within the NHS or in the private sector. Limitations The research draws on participant recall over a lengthy period characterised by evolving QI approaches and system-level change. Conclusions Little robust evidence remains of PW leading to a sustained increase in the time nurses spend on direct patient care or improvements in the experiences of staff and/or patients. PW has had a lasting impact on some ward practices. As an ongoing QI approach continually used to make ongoing improvements, PW has not been sustained, but it has informed current organisational QI practices and strategies in many trusts. The design and delivery of future large-scale QI programmes could usefully draw on the lessons learnt from this study of the PW in England over the period 2008–18. Funding This National Institute for Health Research Health Services and Delivery Research programme.
Background The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency. Objective To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention. Design Multiple methods within six hospitals including 88 interviews (with Productive Ward leads, ward staff, Patient and Public Involvement representatives and senior managers), 10 ward manager questionnaires and structured observations on 12 randomly selected wards. Results Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies (eg, displaying metrics data; storage systems) have remained in place for up to a decade after initial implementation as have some specific practices (eg, protected mealtimes). Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation. Conclusions As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes.
Glenn Robert
added an update
EVALUATING THE TEN YEAR IMPACT OF A QUALITY IMPROVEMENT INTERVENTION IN CLINICAL MICROSYSTEMS: A NATIONAL STUDY OF THE PRODUCTIVE WARD
As part of our ongoing study we conducted two complementary online surveys of all acute NHS hospitals in England, using open and closed questions. The first was a 10-item survey sent to Directors of Nursing (DoNs), asking strategic-level questions about their hospital’s use of PW. The second survey was sent to the current / most recent PW lead, and requested more detailed information to explore their adoption and implementation approaches; perceptions of the PW programme and its impacts; and the capture and use of local impact data. We found that a significant proportion of previous adopters still use some elements of PW regularly, some 10 years after it was initially introduced. Regular, systematic use of PW to identify and improve problem areas appears to be uncommon but PW principles and some material/processual/spatial impacts remain evident.
These findings were recently presented as a poster at the HSR UK conference July 2017
 
Peter Donald Griffiths
added a research item
Background Releasing Time to Care: The Productive WardTM(RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit¿s existing QI capacity on their ability to engage with RTC as a program for continuous QI.Methods We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.ResultsThe results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.ConclusionsRTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.
Glenn Robert
added 4 research items
Purpose: This paper aims to focus on facilitating large-scale quality improvement in health care, and specifically understanding more about the known challenges associated with implementation of lean innovations: receptivity, the complexity of adoption processes, evidence of the innovation, and embedding change. Lessons are drawn from the implementation of The Productive Ward: Releasing Time to Care programme in English hospitals. Design/methodology/approach: The study upon which the paper draws was a mixed-method evaluation that aimed to capture the perceptions of three main stakeholder groups: national-level policymakers (15 semi-structured interviews); senior hospital managers (a national web-based survey of 150 staff); and healthcare practitioners (case studies within five hospitals involving 58 members of staff). The views of these stakeholder groups were analysed using a diffusion of innovations theoretical framework to examine aspects of the innovation, the organisation, the wider context and linkages. Findings: Although The Productive Ward was widely supported, stakeholders at different levels identified varying facilitators and challenges to implementation. Key issues for all stakeholders were staff time to work on the programme and showing evidence of the impact on staff, patients and ward environments. Research limitations/implications: To support implementation, policymakers should focus on expressing what can be gained locally using success stories and guidance from "early adopters". Service managers, clinical educators and professional bodies can help to spread good practice and encourage professional leadership and support. Further research could help to secure support for the programme by generating evidence about the innovation, and specifically its clinical effectiveness and broader links to public expectations and experiences of healthcare. Originality/value: This paper draws lessons from the implementation of The Productive Ward programme in England, which can inform the implementation of other large-scale programmes of quality improvement in health care.
Purpose – The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/methodology/approach – Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Caret in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n¼79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings – Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense of permission to lead change, leader’s actions to spread learning and sustain improvements. Originality/value – This paper offers useful perspectives in understanding informal, emergent, developmental or shared “new” leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader’s boundary spanning activities to spread learning and sustain improvements.
The progress of the Productive Ward programme has been variable. This article outlines a study that investigated the experience of implementing the programme in different hospitals and the lessons that can be learnt.
Glenn Robert
added an update
A brief update on progress with our study of the Productive Ward in England attached - gives highlights from survey of Directors of Nursing in England.
A second survey is now open for past and present Productive Ward leads from acute hospitals in England to give their views on impact over time of the Productive Ward (contact details for how to participate in attached).
 
Peter Donald Griffiths
added a project goal
Clinical microsystems' - and how well they work - are the focus of this call for research proposals. A clinical microsystem can be any health care team providing services to patients, for example, a General Practice, a hospital ward or a clinical unit. This proposal is to find out whether a way of trying to improve how staff in hospital wards work - called the 'Productive Ward' - has been successful in NHS acute hospitals in England and to help managers, doctors and nurses who are continuing to use the approach to make it as useful as possible. The Productive Ward aims to allow nurses on wards to change the way they work so that they are more efficient by reducing waste and stopping nurses from spending time on activities that do not benefit their patients. The Productive Ward was first tried in the NHS in 2007 and in the 8 years that have followed most hospitals in England have used this approach as a way of making some or all of their wards work better. Although the NHS has spent significant amounts of money on using the Productive Ward (over £50 million) still little is known about whether it has worked or not or what its effect has been on patients and carers. Nor do we know whether hospitals that began to use it in 2007 have seen any benefits last. The research team previously studied how the Productive Ward spread through the NHS and have a list of all the 102 hospitals that had began using it by 2009. The researchers now plan to find out whether the wards in those hospitals are working better now than wards that either started to use the Productive Ward at a later date or who have not used the Productive Ward at all. The researchers will survey all 160 NHS acute hospitals in England to update their earlier study and find out whether they are currently, or have previously, used the Productive Ward and, if they have, the way in which they have used it and whether it has worked well. From the results of the survey the researchers will identify 3 hospitals that began to use the Productive Ward first and 3 that started later. The researchers will then carry out research in 2 wards in each of these 6 hospitals. The researchers will interview staff and patients in the hospitals to find out whether using the Productive Ward has brought about any benefits, such as whether nurses spend less time looking for equipment and other unproductive activities that the Productive Ward was supposed to reduce. The researchers will also try to find out whether there have been other benefits of using the Productive Ward, such as developing nurse leaders and whether different ways of introducing the approach have had any impact on the success or otherwise of the Productive Ward. Finding this out will help managers, doctors and nurses and other clinical staff in other hospitals think about how they are using the approach and whether they should do things differently in order to maximise it's impact. The research will take 30 months to finish and will answer whether using the Productive Ward over a 10 year period (2008-17) has made wards in English NHS hospitals more efficient, with less time wasted by nursing staff on activities that do not benefit their patients whilst also improving staff experiences too.