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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.
International Journal of Health Care Quality Assurance
Emerald Article: Implementing large-scale quality improvement: Lessons
þÿfrom The Productive Ward: Releasing Time to Care!"
Elizabeth Morrow, Glenn Robert, Jill Maben, Peter Griffiths
Article information:
To cite this document: Elizabeth Morrow, Glenn Robert, Jill Maben, Peter Griffiths, (2012),"Implementing large-scale quality
þÿimprovement: Lessons from The Productive Ward: Releasing Time to Care!"", International Journal of Health Care Quality Assurance,
Vol. 25 Iss: 4 pp. 237 - 253
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Implementing large-scale quality
improvement
Lessons from The Productive Ward: Releasing
Time to Caree
Elizabeth Morrow, Glenn Robert and Jill Maben
National Nursing Research Unit, King’s College London, London, UK, and
Peter Griffiths
School of Health Sciences, University of Southampton, Southampton, UK
Abstract
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 Careeprogramme 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.
Keywords Lean thinking, Productive ward, Efficiency, Quality improvement, Diffusion of innovation,
Lean production, Hospitals, United Kingdom
Paper type Research paper
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm
This work was commissioned by the National Health Service Institute for Innovation and
Improvement in England (NHS Institute). Helen Bevan, Lizzie Cunningham and Lynn Callard at
the NHS Institute provided data about the uptake of the programme and supported liaison with
NHS staff. Diane Ketley provided comments on a draft of this paper. The authors thank all those
who participated in this study. Victoria Wood undertook interviews with NHS staff in case study
sites and contributed to the analysis and writing up of case study interview data. Rebecca
Blackwell provided administrative support.
Large-scale
quality
improvement
237
Received 1 December 2009
Revised 19 July 2010
Accepted 12 January 2011
International Journal of Health Care
Quality Assurance
Vol. 25 No. 4, 2012
pp. 237-253
qEmerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861211221464
Background
Like many other westernised countries the health service in the UK is under pressure to
perform better with fewer resources. Policymakers and healthcare professionals face
the challenge of increasing the efficiency and quality of services provided (Ham, 2004).
This paper is concerned with facilitating large-scale quality improvement in health
care. Specifically, how staff working at different levels of a health system can
implement innovation to improve the quality of the system they work within (Hartley,
2005).
The paper draws on the insights gained by the NHS Institute’s The Productive
Ward: Releasing Time to Caree(The Productive Ward) Learning and Impact Review
(undertaken February-June 2009). The Productive Ward aims to empower ward teams
to identify areas for improvement by giving staff the information, skills and time they
need to regain control of their ward and the care they provide. Here we examine some
of the challenges and facilitators to national implementation from the perspective of
three stakeholder groups: policymakers, senior managers and healthcare practitioners.
These insights are discussed in relation to current theory and evidence on the
challenges to implementation of Lean-inspired innovations in health care.
The diffusion of innovation literature offers a useful existing body of theory and
evidence to inform the adoption and use of quality improvement initiatives by
healthcare organisations. The term innovation has been defined as a set of ideas,
principles and practices that may be adopted in whole or in part (Rogers, 1962).
Innovating organisations critically seek and adapt innovations to achieve their
strategic goals (Pettigrew and Fenton, 2000). There are associated terms to describe the
uptake, spread and sustained use of innovations in healthcare; however these tend to
be used interchangeably and to mean different things in different contexts (Buchanan
et al., 2007a, b). The term dissemination is generally used to mean intentionally and
actively spreading a message to a defined target group (Mowatt et al., 1998). While
diffusion refers to the informal processes and networking that can help to spread
abstract ideas and concepts, technical information and practices within a social system
(Rogers, 1962). Greenhalgh et al. (2005) use the innovations literature to develop a
diffusion of innovations framework, comprising four broad domains of programme
adoption and implementation: the innovation itself; the wider social/healthcare context;
the implementing organisation; and linkages between the previous three domains.
“Lean thinking” (Lean) is a relatively new innovation in healthcare when considered
against the history of its development and use in the commercial sector (Womack et al.,
1990). However, there is strong evidence of the widespread use of Lean across the
healthcare sector (Young and McClean, 2008; Radnor and Boaden, 2008; Brandao de
Souza, 2009). Lean can help organisations to refine working processes and practices by
focusing on the values which drive systems (Rooney and Rooney, 2005) and to
maximise operational processes towards achieving such values (Crump, 2008). For
example, the five principles of Lean put forward by Womack et al. (1990) focus upon
identifying value from the point of view of the customer and then on making the value
steps flow continuously. In manufacturing industry, Lean has been used to achieve
economic and operational benefits (Taylor, 2006). While in the healthcare sector Lean
has helped to achieve improvements in efficiency and safety in hospitals in the US
(Savary and Crawford-Mason, 2006), Australia (Bem-Tovim et al., 2007) and the UK
(Jones and Mitchell, 2006, Fillingham, 2007).
IJHCQA
25,4
238
Previous authors have developed classifications to describe Lean implementation.
Hines et al. (2008) express implementation as progressing through typical stages
towards an organisation becoming “Lean”. Alternatively, Pettersen (2009) argues that
there is no consensus on a definition of Lean and thus organisations should make
active choices and adapt the concept to suit their needs. It has been debated as to
whether Lean has been implemented in a “complete” way in the public sector or in a
way that embraces the underlying philosophy (Radnor and Boaden, 2008). In the case
of healthcare Brandao de Souza (2009) develop a taxonomy of approaches to
implementation from the literature, including “manufacturing like” approaches,
“managerial and support” and “organisational” applications. Emiliani (2008) suggests
implementation can be “fake Lean” rather than “real Lean”. Fake Lean is where an
organisation uses just the tools with an emphasis on rapid improvement rather than
long-term change. Real Lean is felt to mean showing a commitment to continuous
improvement using tools and methods to improve productivity; as well as showing
respect for people through leadership behaviours and business practices.
In The Productive Ward Lean is developed into a programme which aims to give
healthcare managers and practitioners the tools by which to make efficiency savings in
the care they deliver. The Productive Ward was devised and developed by the National
Health Service Institute for Innovation and Improvement (NHS Institute) in England.
Members of the NHS Institute worked with industrial partners from Toyota to look at
how care delivered in hospital ward settings could be streamlined. The Productive
Ward programme is different to Lean per se because it aims to empower frontline staff
to improve the quality of the care they provide. The programme consists of 13 modules
and tools along with clinical facilitation, conferences, training and web-based support.
Healthcare organisations following the programme are encouraged to implement three
foundation modules in the first instance, these are: Knowing How We are Doing, Well
Organised Ward, and Patient Status at a Glance.
Drawing from the innovations literature, it is possible to identify four types of
challenges to implementing innovations such as The Productive Ward in a healthcare
system. The first of these challenges is receptivity. Staff perception is known to play an
important role in receptivity to an innovation (Greenhalgh et al., 2005) and there is a
need to further understand the influence of perception (Brandao de Souza, 2009) and
social context (Dopson et al., 2002) in the diffusion of innovation. Specific potential
issues in relation to the implementation of Lean are concerns about staff resistance to
commercial ideas and disinterest in working to productivity values (Young and
McClean, 2009).
The second challenge reported in the innovations literature is to understand the
complexity of adoption processes. Previous research shows that the decision to adopt a
programme such as The Productive Ward is not a one-off, all-or nothing event but a
complex and adaptive process (Van de Ven et al., 1999). In their review of the field
Greenhalgh et al. (2005) identify a series of critical factors in the diffusion of
innovations, including: socio-political influences, the needs of the adopters, the
presence and actions of external change agencies, mechanisms of spread, perceived
benefits of the innovation, operational attributes of the innovation and the
organisational context of adopting organisations. These factors are known to be
interconnected in a way that brings the social and technical together (Joosten et al.,
2009). Previous authors have argued that it is important to gain insights into the
Large-scale
quality
improvement
239
complexity of processes and decisions (McNulty and Ferlie, 2002), in organisations
made up of different healthcare providers (Pettigrew et al., 1992), and the logic and
structures of professionalism (Kitchener, 2002).
The third challenge is generating evidence about an innovation such as The
Productive Ward. In particular, the problems of attributing, documenting and
interpreting the implementation costs and benefits of any specific initiative (Berwick,
2003). Part of this challenge is that impact depends on local contexts for change and
how the mechanisms of change are used (Ham et al., 2003).
The fourth challenge is embedding change. Buchanan et al. (2007a, b) examine the
implementation of a number of national large-scale quality improvement initiatives in
the UK and identify common challenges as including: replacing old ways of working
and developing appropriate policy, practice and research to support spread and
sustainability. There is also the issue of how best to establish long-term responsibility
for quality programs (Ham et al., 2003).
Aims
The aim is to use the case of The Productive Ward programme to gain insights into
four areas of challenges identified from the current research literature on innovations,
focusing on the use of Lean Thinking in health care. These challenges can be
summarised as: staff receptivity, the complexity of adoption, evidence of the
innovation, and embedding change.
The aims of the national Learning and Impact Review evaluation study which this
paper draws upon were:
(1) To describe and determine how The Productive Ward evolved and spread
including identifying the characteristics and key attributes of The Productive
Ward that caused the “pull” phenomenon from NHS frontline staff.
(2) To map current uptake and initiatives under The Productive Ward programme.
(3) To determine the extent to which The Productive Ward programme: provides
staff with the information, skills and time they need to regain control and
identify areas for improvement; increases the proportion of time nurses spend in
direct patient care; improves experience for staff and patients; facilitates
improvements in efficiency in terms of time, effort and money through for
example structural changes to the use of ward spaces; and motivates nurses and
other staff to implement the programme, to initiate change and the extent to
which their work satisfaction is influenced by aspects of Productive Ward
participation.
(4) To determine any facilitators and inhibitors of implementation, initial success
and sustainability of The Productive Ward programme.
Methodology
The Learning and Impact Review employed a mixed method research design. Part of
the study was to use NHS Institute purchasing data to quantitatively estimate adoption
rates nationally and these findings are discussed elsewhere (Robert et al., 2011). This
paper makes use of the “rich” qualitative accounts (Langley, 1999) provided by three
different “stakeholder” groups (Golden-Biddell and Locke, 1997) policymakers,
organisational managers and healthcare practitioners who had personal experience of
IJHCQA
25,4
240
implementing the programme. As this part of the study aimed to explore the
perceptions and experiences of stakeholders we used a qualitative and inductive
approach (Denzin and Lincoln, 1998). We did however make use of the aforementioned
diffusion of innovation framework (Greenhalgh et al., 2005) to structure the study
around four broad domains of programme adoption and implementation: the
innovation itself; the wider social/healthcare context; the implementing organisation;
and linkages between the previous three domains.
It was necessary to use different techniques for participant sampling and data
collection because of the different roles, professional practices and working patters of
the three stakeholder groups. These were as follows:
(1) To gain an understanding of the development and strategic implementation of
the programme we purposely selected 15 national and regional policymakers to
interview on the basis of their leadership positions; and aiming for
representation of at least five of the ten strategic health authority regions in
England. Semi-structured interviews were conducted face-to-face or by
telephone depending on the preference of the interviewee. Each interview
lasted 15-35 minutes and covered questions on: personal role and involvement
in the programme, experiences of implementation, barriers and challenges,
outcomes and sustainability. These were audio recorded and transcribed for
analysis.
(2) To target as many service managers and staff with organisational-level
implementation across England as possible we developed a national online
survey (using the website SurveyMonkey.com). This was advertised using
email networks and the professional press and a prize of £50 gift voucher was
offered as an incentive to complete the questionnaire. The survey contained
questions on personal information, support/organisational context, progress
with implementation, barriers and facilitators, impact and “advice for others”. A
total of 150 self-selecting organisational leads, service managers and clinical
leads responded from 96 different healthcare organisations across England.
(3) To gain a more detailed picture of local implementation from “ward to board”
we made use of in-depth case studies (Yin, 1993) of five hospitals in different
regions of England. Sites were selected from an NHS Institute record of 60
implementing hospitals according to the following criteria: geographical
location (five different strategic health authority regions), stage of
implementation, type of support package purchased from the NHS Institute
(standard or accelerated), and willingness to participate. Within each site
interviews were undertaken opportunistically with 55 staff nominated by
Productive Ward leads. Further detail of the hospitals and participating staff is
provided in Table I.
The analysis of the qualitative data involved reading through each interview transcript
to identify key themes (Langley, 1999), and categorising issues according to the
domains of the diffusion of innovation framework. The quantitative survey data were
analysed using statistics; presented as percentages in the full results (NHS Institute
and NNRU, 2010). Cross case analysis (Yin, 1993) of the case study hospital sites aimed
to examine issues to do with organisational context such as managerial support,
resourcing and leadership.
Large-scale
quality
improvement
241
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5
Date of initiation August 2007 (Mid)-2007 October 2007 March 2008 February 2008
NHSI support
package
Learning partner Accelerated No support package Accelerated Accelerated
Foundation status Non foundation trust Non foundation trust Foundation trust Non foundation trust Foundation trust
Internal programme
title
“Releasing time to care” Productive Ward Productive Ward Productive Ward Productive Ward
Strategy Overall organisational plan
for implementation but
rolled out in stages; wards
undergo selection process to
join
Whole-organisation
implementation (one of first
two whole-hospital pilots)
Phased whole hospital
implementation; initially
launched using previous
service improvement
experience rather than NHSI
package; subsequent phases
using package
Focused implementation
with selected wards
supported by dedicated
Productive Ward facilitator
Planned and organised
strategy for implementation
Resourcing As an original learning
partner received support
from NHS Institute. Have
dedicated Productive Ward
team skilled in change
management
Dedicated service
development team with
extensive clinical experience
Key executives and staff
previously experienced in
improvement
methodologies; in-house
service improvement team,
but no dedicated PW
facilitators at launch; June
08 two dedicated facilitators
in place
Dedicated Project Lead and
facilitator, both clinically
qualified; new resource
which will expand as needed
Dedicated PW
implementation team
including service
improvement and clinical
specialists
Priorities/goals Whole hospital rollout Whole hospital
transformation with new
culture uniting the two
merged hospitals; driving
improvements in quality of
care; eventual goal is total
“Productive Trust”
Full Productive Hospital;
raising standards in quality
of care
Spreading learning and
improvements across the
whole organisation
Eventual whole hospital
rollout. Achieving
improvements in efficiency
and patient’s experience;
“Turnaround to
transformation”
Achieving service
improvement in terms of
both efficiency and quality.
Capturing learning so far
and showing impact of
change
Eventual aim: productive
hospital; all-ward rollout to
be phased over two year
period
(continued)
Table I.
Summary of case study
sites
IJHCQA
25,4
242
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5
Key features of
implementation
Allowing staff to learn by
doing, adapting Productive
Ward to the contexts they
are working within
Adapting and developing
metrics to their priorities,
e.g. developing module-level
indicators to monitor
modules implemented so far
Developing tailored
leadership programme to
support staff to implement
the Productive Ward
programme
Focus on staff
empowerment to encourage
participation and
innovation; ward teams
themselves, rather than their
matrons, lead applications
to join
Communication and sharing
of learning encouraged, both
within and between ward
teams; wards within
particular specialisations
recruited as cohorts together
to facilitate shared learning;
also organisation’s own
“Releasing Time to Care”
newsletter published
Networking event for each
new cohort approx four
weeks before joining; each
ward to define their “vision”
for implementation;
extensive
Trust-wide communications
and networking
opportunities for
participants; ward
communication review
currently in progress
Ongoing action learning
sets, extensive training
sessions and time out days
for each cohort; now also
introducing “Leading a
Module” day for registered
nurses
Regular “ward to board”
PW steering group meetings
headed by chief executive
All departments involved,
including facilities and
Estates, which has a
dedicated matron focused on
PW implementation
Patient representative
assigned to PW steering
group
Recognition of need to
identify and resolve any
implementation problems in
order to promote
sustainability
Launched programme on
three wards without
Institute support. Re-
launched in Jan 2008 with
NHS Institute PW
programme
Preferred title reflects
practical approach
characteristic of this site
Extensive experiential
learning at all levels, of
necessity as PW still in
development when project
initiated here
Effectiveness through
recognition of value of
identifying and
implementing small step
change; accessible and
manageable by all
Developed solutions in all
areas including leadership
approach, methodologies,
and synergy of PW with
other performance tools and
initiatives; executives
equally hands-on in their
involvement with PW
Pilot site for Productive
Operating Theatre
Supporting and facilitating
staff to make Productive
Ward their own project
Wards selected for
participation according to
NHSI guidelines
Practical/empirical and
flexible approach to
development of best practise
Full cross-functional team
involvement; chief executive
and director of estates
involved in monthly PW
project board meetings with
staff
Special emphasis on
managing resources
In-house DVD produced to
promote PW ideals and
approaches
Also participating in
Productive Theatre
development
Supporting and facilitating
staff to make Productive
Ward their own project
Wards selected for
participation by project
manager and team
Regular and extensive
communications with teams;
networking opportunities at
all levels, through public
“PW/RTTC” status board,
weekly ward/monthly
steering group meetings etc.;
constant contact with chief
executive
Full use of other available
training programmes
synergistic with and
supportive of aims of PW
Full cross-functional team
involvement; involved all
directorate nursing heads in
Institute induction days
from outset; estates,
supplies and catering
representatives on
Productive Ward team
In-house DVD produced to
promote Productive Ward
ideals and approaches
Participating in Productive
Theatre development
Table I.
Large-scale
quality
improvement
243
Results
The results presented here emphasise the main key facilitators and challenges to
implementation as they were expressed by policymakers, senior managers and
healthcare practitioners. Key issues identified by the thematic analysis are
summarised in Table II. Selected detailed results from the full report are presented
below to expand upon these themes. To ensure organisational and individual
anonymity we have identified the region of England where participants were employed
but not their organisation’s name.
National and senior policymakers
The interviews with national and regional policymakers revealed a sense of
commitment to providing support to healthcare organisations to implement this
particular programme and enable long-lasting improvements to the way services are
delivered. A key theme of the interviews was to find ways to communicate the
potential for change to NHS organisations – who may not previously have perceived
Lean techniques to be relevant to themselves or healthcare settings. Part of the
response from policymakers was to recognise that different professional communities
(managerial, quality improvement specialists, and clinical staff, for example) are likely
to interpret the aims and impact of a programme such as The Productive Ward in
different ways. Consequently, there was a common view that policymakers needed to
assist adopting hospitals to raise awareness about the potential and need for change to
“win the hearts and minds” of staff. A way of achieving this was to create a vision that
conveyed the meaning of the innovation to different staff groups – in other words to
“frame the innovation” (Bevan, 2009) in a way that creates an emotional connection
with core professional values:
The language of “Releasing time to care”, rather than cutting out waste connects with the
desires of clinical staff to spend more time directly caring for patients (Clinical Facilitator,
NHS Institute).
At the same time the language of “productivity” speaks to the members of a hospital
board and stimulates service manager’s agenda of meeting efficiency and quality
goals. Five respondents, who were strategic health authority (SHA) regional leads, said
their role had been to help to disseminate information to hospitals and to stimulate
interest in the programme. All of the SHA leads had promoted the potential benefits of
implementation with senior NHS leaders, explaining how the programme could assist
with the transformation of services, link with existing programmes and evidence of
best practice:
My role within the SHA, it’s about learning the lessons and sharing best practice, and being
able to facilitate networking (Regional lead for clinical standards).
Such top-down “dissemination” was supported by standard written materials from the
programme, for example the Executive Leaders Guide. However, a key challenge was
facilitating access to suitable and sufficient training and support, simply because of the
large number of hospitals taking up the programme nationally. For this group of
stakeholders it was important to roll the programme out in a planned and measured
way and to link the work with other quality initiatives, yet this was an aspiration for
implementation, which instead tended to be driven by the interests and enthusiasm of
senior managers within hospitals.
IJHCQA
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244
Stakeholder perspectives
National and senior policymakers
(interviews) Senior managers (national survey)
Healthcare practitioners (case studies/
interviews)
Key facilitators Providing regional level support to
healthcare organisations
Working with provider organisations to
develop a clear vision of the innovation
Providing support for planning
Providing support for networking and
learning
Working with provider organisations to
align the programme with organisational
targets
Dedicated project leadership
Strong support from senior staff
(champions/ steering groups)
External support (facilitation, study
days, networking)
Enthusiasm and talent of ward managers
and staff
Time for staff cover
Funding for implementation and budgets
Communication and feedback to staff and
patients
Good information about the initiative
Feeling there is a need for change
Seeing PW as a simple practical solution to
real problems
Valuing the initiative/NHS Institute role
Accessibility of modules and resources
Self-nomination of wards to take part
Emphasising local ownership and
empowerment of ward staff
Sufficient resources and support, allocated
budgets for backfill of staff time
Key challenges Challenges of winning the hearts and
minds of all staff
Access to suitable and sufficient training
and support
Rolling the programme out in a planned
and measurable way
Keeping the programme “live”
Linking the programme with the
transformation of services, existing
programmes and evidence of best
practice
Staffing pressures (workload, bed
pressures, turnover, sickness absence,
winter pressures, insufficient bank staff)
Generating enthusiasm
Engaging non-ward based staff (matrons
and medical staff)
Finding time
Finding resources/hold-ups in financing
Poor inter-departmental relationships
and delays
Balancing work pressures/clinical
demands
Multiple organisational targets and quality
initiatives
Staff ownership and understanding of PW
metrics
Table II.
Perceived facilitators and
challenges to programme
implementation
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Senior managers
A national online survey of Productive Ward organisational leads (150 service
managers and clinical leads in hospitals) showed that nearly all agreed that “The
Productive Ward fits well with what we want to do in this organisation” (92.3 per cent,
102 of 114) and that “Releasing time to care is a cause that I strongly identify with”
(96.5 per cent, 109 of 113). While it is not surprising that this group of stakeholders
were very supportive of the programme, it was generally the case that they were
attracted to the programme because they perceived its potential for impact on service
settings:
It was the frustrations you have had for a long time, and stopped thinking about, because
they haven’t changed. Productive Ward was actually a project that was saying, “Well let’s
stop, let’s look at those again now, and actually spend some time trying to fix them”
(Productive Ward Facilitator, South West region).
For respondents who were senior service managers the availability of resources to
provide dedicated project leadership, to help secure strong support from senior staff
and to “buy in” external support (clinical facilitation, study days and networking) were
key facilitating factors. The majority of survey respondents agreed that leadership and
support from senior staff in their organisation was good (68 per cent, 69 of 107). Despite
high levels of interest and engagement nationally the most significant challenge,
reported by over half of these senior managers, was overcoming staffing pressures.
They faced challenges of generating enthusiasm for the programme often because of
lack of opportunities to engage frontline staff outside of pressurised work
environments. Facilitating factors were to allocate resources for staff cover, work
with the existing enthusiasm and talent of ward managers and staff, and to provide
good information about the programme:
SHA funding for the roll-out of this programme has been invaluable. It has enabled us to have
the essential resource of a full-time facilitator, employ a part time handyman and allocate a
small amount of funding to each ward to use on backfilling staff and equipment (Productive
Ward Facilitator, general hospital South East Coast region).
Senior managers felt it was essential to gain the support of hospital executives, clinical
directors and to collaborate with other managers working elsewhere:
We have steering group meetings, facilitators communicate via face-to-face meetings and
email and networking with other trusts and organisations to share knowledge and experience
(PW facilitator, community hospital South East Coast region).
For the majority of these senior managers being able to show early tangible outcomes
helped to secure ongoing commitment from both their managerial colleagues in the
organisation and frontline healthcare practitioners. The majority (64 per cent, 64 of
100) agreed “There have been measurable improvements as a direct result of The
Productive Ward”. Benefits included better organised working environments, fewer
patient safety incidents, and cash savings in terms of returned excess stock:
When we started the project we had complaints from relatives, high number of falls, high
incidence of errors, the nurses were worn out and demoralised, and the patients felt the
domestics looked after them. Now the ward team are motivated we have not had a complaint
for seven months the number of falls has decreased (Matron, NHS Foundation trust East
Midlands region).
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There were some reports of improvements in patient flow where Productive Ward
work had reduced repetition and interruptions during patient handovers. At the time of
the survey (March-April 2009) most senior managers had begun to see evidence of
cumulative gains, such as increases in staff commitment to quality improvement, for
their organisation that extended beyond immediate short-term benefits:
Staff previously disinterested in service improvement are now taking the lead in changes at
ward level. They are empowered to challenge and feel supported to keep going until actions
are resolved (Project manager, general hospital London region).
Other outcomes included improvements in teamwork and departmental collaboration.
It was also felt to be important to promote staff achievements across the organisation
and to invite executives to visit ward areas to hear about developments in the work.
Relatively fewer staff (38 per cent, 38 of 100) felt that patient and public involvement in
the programme was good, which was an issue that we pursued in our case studies and
interviews with healthcare practitioners.
Healthcare practitioners
For healthcare staff working to implement the programme at ward-level the attraction
was the potential to deliver better quality patient care by using their time better. Staff
within all five hospital case study sites described the potential for change and
perceived the programme as offering a solution to some of the day-to-day problems
they were facing with the organisation and delivery of care, for example with the
organisation of patient handovers and meal times. Across the five case study sites
there was a general sense that The Productive Ward programme was valued as being
novel and useful even though different approaches to implementation had been
chosen (see Table I). Healthcare staff described The Productive Ward as giving them a
sense of permission to turn a critically reflective eye on their work practices and to
make suggestions for change. The opportunity for ward teams to choose different
modules to apply to their particular contexts instilled a sense of involvement and
ownership of improvement activities.
As summarised in Table II, for healthcare practitioners, balancing work pressures,
clinical demands and improvement efforts was a continual challenge. This group of
stakeholders in particular talked about the challenge of meeting multiple
organisational targets and undertaking other contemporaneous quality initiatives.
Favouring the implementation of The Productive Ward was the ease of accessibility to
the modules and accompanying resources. The potential for wards to self-nominate to
take part (or elect not to) was also seen as being an important facilitating factor for
implementation. Healthcare staff said they found the materials appealing because they
made use of language, checklists, and concepts that were familiar to them. Financial
resources made available through strategic health authorities, and senior executive
and clinical support were also perceived as being essential to being able to make an
ongoing commitment to adopt and implement the programme. Yet, even when
organisations had achieved successes they found that work on the programme slowed
at particular times because of staffing pressures:
We had a brilliant first year. We flew. Everybody was 100 per cent on board, our first two,
three modules, flew, and we were doing wonderfully. And then January, all of a sudden we
had a very big staff crisis [...] and that changed everything (Ward Sister, South East region).
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At all five case study sites, healthcare staff reported benefits to the social and work
environment, but perhaps most significantly working on the programme was described
by some staff as a long awaited opportunity for personal or career development. Senior
managers at the case study sites explained that the programme was helping to build
leadership skills at ward-level by teaching staff about Lean theory and techniques. A
related challenge was to encourage staff to take ownership of Productive Ward metrics
in order that they can make targeted changes and understand improvements:
Collection of baseline data improves ward cohesion, refocuses on patient centred, safe, quality
care and allows sharing of knowledge/skills/ways of working (Lead Nurse Patient Safety and
Quality, hospice South East Coast region).
Demonstrating change before and after implementation was also perceived to be
important for continued financial support from the hospital board. Typically, however
this was problematic because data was only collated over a relatively short period of
time and it was often not possible to show longer-term trends. Our research at the case
study sites indicated that potentially consistent measures could include routinely
collected data such as falls incidence, infection rates and pressure sore incidence,
further research is being undertaken by the NHS Institute to examine the feasibility of
using measures like these to evaluate the impact of the programme.
Discussion
The main limitation of the Learning and Impact Review is that the data have been gained
from people and hospitals that have engaged with implementing The Productive Ward
programme. Whilst this provides useful information about what supports adoption and
implementation of Lean techniques, further insight could be gleaned from “non-adopting”
hospitals about the barriers to using such approaches. There is also more to learn about
Lean implementation in community health settings. The findings do however help to
provide insights into the challenges identified from the innovations literature in relation to
the adoption and implementation of innovations. These are discussed below.
Receptivity issues
In the case of The Productive Ward, central resourcing and senior executive and board
level backing, as well as the availability of expert support from an external change
agency (the NHS Institute), were key facilitating factors for increasing the receptive
context from the point of view of all the stakeholder groups. In terms of understanding
the influence of social context (Dopson et al., 2002), all three groups of stakeholders felt
it was important to show progress towards meeting quality and efficiency goals.
Healthcare practitioners were generally open to working towards improved efficiency
and productivity – and they recognised the need and potential for change. This
contests the concern that healthcare staff are resistant to commercial ideas and
productivity values (Young and McClean, 2009). There was however some scepticism
amongst healthcare practitioners about focusing too narrowly on productivity as a
primary goal at the cost of quality services and patient experiences. Although these
findings point towards the potential for large scale quality improvement brought about
by direct involvement of frontline staff, there is more to be learnt about how staff
engagement in a Lean-inspired programme affects staff receptivity to subsequent
experiences of innovation (Brandao de Souza, 2009).
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The complexity of adoption
These stakeholder’s experiences of The Productive Ward support Greenhalgh et al.”s
(2005) observations about the complexity of the adoption processes in a system made up of
different healthcare providers and professional cultures. A notable finding was the
variation in perceived timescales of implementation by stakeholders at different levels of
the health system. For national and regional leads, the decision to back the programme in
England with a £50 million investment in 2008 (Johnson, 2008) was quickly
operationalised through strategic regional leads leading to a view amongst these
stakeholders that The Productive Ward was being rapidly rolled out to the NHS. Yet from
the perspective of many healthcare practitioners implementation is only in its infancy.
Previous models of implementation, such as the diffusion of innovation framework
(Greenhalgh et al., 2005), have not generally recognised the significance of different
stakeholder’s perspectives of the pace and scale of implementation. This issue of variations
in perceived progress could have a bearing when defining objective benchmarks and
realistic goals for the implementation of large-scale quality improvement programmes.
Evidence about the innovation
The findings also confirm the importance and challenges of generating evidence about
an innovation. A key issue for all stakeholders was showing evidence of the impact of
The Productive Ward on staff, patients and ward environments. Results from our
research support previous accounts which indicate that The Productive Ward
programme may achieve efficiencies in operational routines (Wilson, 2009), better
organised ward environments (Eason, 2008), better use of patient data (Anthony, 2008),
and improve the safety (Fillingham, 2007) and efficiency of care (Shepherd, 2009,
Torjessen, 2009). However at the present time comparable data about implementation
and impact is not being consistently collected or collated across the health system
leaving the question of whether The Productive Ward has “released time to care”
difficult to answer without making speculative projections (Snow and Harrison, 2009).
A more fundamental problem is what impact can be attributed to this particular Lean
innovation rather than to staff taking on more of a quality improvement role for
example or because of other contemporaneous initiatives. At a local level there was
strong agreement that impact should be measured in ways that take into consideration
the complexity of care environments, how “released time” is then being better spent,
and patient’s perspectives of healthcare. The extent to which this particular
programme enables patient-centred improvement is another complex and far reaching
question, but one which should be taken seriously in a climate of increased patient
choice and public involvement in decision making. One positive step is that moves
towards the use of patient experience data within healthcare settings offers
opportunities to strengthen the “patient voice” in Productive Ward work.
Embedding change
For stakeholders at all levels making change happen getting the programme up and
running within frontline services was the priority at this early stage of
implementation. In addition, policymakers and senior managers expressed concern
about the challenge of embedding change, echoing Emiliani’s (2008) views about
implementation being “fake Lean” where hospitals use the tools for rapid improvement
rather than long-term change. Policymakers and senior managers recognised that
Large-scale
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improvement
249
central resourcing and regional support have helped to spread the programme but they
felt that sustaining early improvements in quality requires enthusiasm from healthcare
staff to embed learning into practice and wider inter-professional routines. This finding
supports previous observations about the need for staff development in change
competencies at all levels, not just for those in senior positions (Buchanan et al., 2007a,
b), which could help with the challenge of establishing long-term responsibility for
quality programs (Ham et al., 2003).
Implications for policy, practice and research
In the case of The Productive Ward, political and professional backing was
fundamentally important to creating a receptive context within the health service for
this particular innovation. Framing Lean in terms of “releasing time to care” created an
emotional connection between healthcare practitioners and Productive Ward work.
Dissemination of the programme focused on expressing what could be gained locally at
a time of wider political and professional debate about productivity and efficiency in
public services. It is important for national policymakers and senior managers
therefore not to underestimate the power of local implementation stories, successes,
and guidance from “early adopters”. These have the ability to inspire other staff to see
the potential benefits for them. Compiling such information in an accessible central
resource, for example a national or organisation-based website, helps to address the
challenge of winning the “heart and minds” of all staff. Whilst senior managers
generally did appreciate the advantages of communicating implementation successes
within their own organisations, they may need encouragement to share their own
learning with other teams and organisations and to seek supportive relationships their
employing organisation. In relation to Hartley’s (2005) observations of innovation in
public services building such links could help to “instil a belief” across the healthcare
system that an innovation can succeed.
Within hospitals the decision to adopt The Productive Ward and to replace old
ways of working can be aided by introducing new protocols, new routines and new
types of information into the system but these changes were embedded when they
were developed and “owned” by healthcare practitioners themselves. There is a clear
role for clinical educators and professional bodies in spreading good practice and
supporting the development of change competencies at a ward-level. One suggestion is
to create links to formal accreditation schemes and professional development
opportunities in higher education.
In the longer-term, further research could help to secure support for the programme
by generating evidence about the innovation, and specifically its clinical effectiveness.
Research could also assess the broader benefits of the programme the impact of “real
Lean” (Emiliani, 2008) to the social and work environment through, for example,
improved working relationships, communication, improved staff skills and knowledge.
There is also much to learn about the broader links between innovations in health
service efficiency and public expectations and experiences of healthcare, such as how
to link the work with patient feedback about care they expect and have experienced.
Conclusions
The Productive Ward: Releasing time to care programme has a huge perceived value
amongst those policymakers, managers and healthcare staff who have helped to
IJHCQA
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implement it in English hospitals. The programme has been well received by a range of
stakeholders because it frames Lean in a way that creates an emotional connection and
it emphasises what can be gained at a local level – time to care. Support, in terms of
central resourcing and senior executive and board level backing, as well as the
availability of accessible materials and support from an external change agency (the
NHS Institute), have been key facilitators in the adoption and implementation of this
particular innovation. There is significant potential to gain further evidence about
implementation as the programme is implemented in Scotland, Northern Ireland and
Canada. This study of The Productive Ward in English hospitals shows stakeholders
at different levels of the health system have experienced a range of challenges and
facilitating factors 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. Taken together this research shows that Lean initiatives are well
received when they are connected with establishing lasting improvements to
healthcare services that align with the professional values of staff who work within
them.
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Corresponding author
Elizabeth Morrow can be contacted at: Elizabeth.morrow@kcl.ac.uk
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... Other 3 (10) a Total number of possible respondents to this question, N = 31. Percentages do not add up to 100 as multiple responses were invited. ...
... In collaboration with the NHSI, authors of this report (JM, PG and GR) and colleagues undertook research in the period 2009-10 exploring the development, early adoption and implementation of PW in England. 3,5,9,10 This earlier research established that 36% (140) of all NHS trusts (acute and non-acute) had adopted PW [i.e. they had purchased either an accelerated (n = 109) or a standard (n = 31) support package] by March 2009, with large variation between geographical regions ( Table 3). The number of wards within adopting trusts at that time was highly variable, but was estimated by the NHSI to be 35% on average. ...
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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.
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