The Lean approach on the Productive Ward

Assistant Director of Nursing,

Nursing Development Centre,

Nottingham University Hospital, UK

Nottingham University Hospitals NHS Trust (NUH) was formed in April 2006 from a merger of two large hospitals: Nottingham City Hospital and the Queen’s Medical Centre. The Productive Ward provided an opportunity for the trust to engage nursing and midwifery staff in delivering better-quality care in a consistent manner throughout the organisation. All our inpatient wards are currently in various stages of implementation of the Productive Ward.

The Lean system of production grew out of the complexities of car manufacture. From 1913–1926, Henry Ford mastered the production line methodology, creating the most efficient system to date for creating and assembling standard components that were accurate and consistent in quality. Ford’s process brought great efficiency but also large delays in total production throughput, over-reliance on expensive capital equipment and an inability to provide variety. 

In the 1930s and 1940s, Kiichiro Toyoda, Taiichi Ohno and others at Toyota began to look at simple process innovations to provide not only continuity of flow but also variety and flexibility. Toyota developed the ‘Just in Time’ concept for delivery of parts to minimise storage; the system was further developed in the 1950s by Taiichi Ohno using Kanban systems to simplify implementation. In the 1960s, Lean management methodology was developed further by Toyota, and William Deming developed the ‘Plan, Do, Check, Act’ cycle to aid problem solving and continuous improvement. In the 1970s, the Toyota Production System was refined and finally published to encapsulate the principles adopted by Toyota. These were subsequently labelled Lean manufacturing.

‘Lean’ was coined as a term by Womack et al(1) in 1990 to describe the philosophy and methods used by Toyota and other companies to organise their processes in order to deliver value to the consumer. Womack and Jones(2) outlined five steps to introduce Lean into an enterprise – the five steps are a continuum, not a recipe from start to finish:

1. understand and specify value – what is valuable to the customer

2. understand the value stream and remove non-value added steps

3. make the remaining steps flow without hindrance

4. when the process is flowing, allow the customer to pull the service or product

5. pursue perfection by reducing waste in the system.

After examining some early implementations of Lean in a healthcare context, Jones and Mitchell(3) concluded that Lean in healthcare is just as applicable as Lean in industry, with the key difference being that the patient substituted is for the customer. 

The Productive Ward adopts Lean principles as used in manufacturing. Lean is being increasingly adopted by all types of organisation as a sustainable method to improve quality, cost and delivery of goods and services and there is a trend for healthcare organisations to adopt Lean principles as a vehicle for continuous improvement.(4) 

The Productive Ward is a national initiative designed by the NHS Institute for Innovation and Improvement (NHSI).(5) The aim is to help clinical teams review the way that key activities are undertaken on wards in order to remove waste and release time to provide more direct patient care. It is a systematic approach, based on Lean service improvement principles, to improve the reliability, safety and efficiency of care and improve the experience of both staff and patients. Across the NHS, there is great variation in patient experience of hospital wards. We see examples of wards providing outstanding patient care next to wards that struggle to cope with the patient workload. In some wards, there is cohesive teamwork and effective decision making, involving the range of clinical professionals. In others, there is an undercurrent of dissent caused by poor communication and weak coordination. We frequently observe dedicated, talented ward staff delivering good care in spite of the system, not because of it. We also observe that the difficulties many ward staff encounter are caused not by lack of ward resources, but by the way that the ward and its nursing team is organised and managed. 

The Productive Ward was developed in close collaboration with a small number of hospital test sites, including NUH as a whole hospital test site. The programme has now been adopted by approximately 80% of NHS Trusts nationwide. Research carried out by the NHSI found that ward nurses in acute settings spend an average of only 40% of their time on direct patient care.(6) This is supported by research carried out by Nursing Times, which shows that nearly 75% of nurses feel that they do not spend enough time on direct patient care, and 90% of those polled say that patient care suffers as a result.(7)

The programme is designed to provide a long-term sustainable change to working methods that are constantly revisited. The initial progress through the modules (see below) takes one-to-two years. It takes time to progress through the changes to ensure that change is driven and implemented by the ward sisters working on the wards and that the changes made are adequately thought through and sustainable. The tools used empower staff at the frontline to own and embed change and to routinely question how things are done; this is energising and can foster pride and good team-working. 

The Productive Ward has eleven modules focused on key activities at ward level. Three foundation modules underpin the other eight modules. The foundation modules are: 

• knowing how we are doing: understanding and using measurement to drive improvement 
• well-organised ward: being able to find things first time, every time 
• patient status at a glance: using the patient white board to aid communication and discharge planning, further developed to incorporate the morning ‘board round’.

The eight other modules focus on the key activities: medicines; admissions and discharge; shift handover; meals; nursing procedures; patient hygiene; patient observations; and ward rounds. The module approach based on Lean methodology analyses the main tasks taking place on a ward. These tasks, such as medication and meal rounds, are then redesigned to ensure they are patient‑focused and easier for staff to perform. The programme often focuses on simple ideas, such as altering patient handover times, reorganising storage facilities and making better use of data. It also provides a systematic and inclusive approach to improving the reliability, safety and efficiency of the care delivered in a ward. The module tools empower front-line ward staff to own and embed change, and to routinely question procedures. Spread of the process modules at NUH is shown below. 

There are a total of eleven modules to implement. Wards at NUH receive four months’ support (half a day each week) from a project nurse to implement the three foundation modules and one other key activity module, for example clinical observations. After four months’ support, wards are expected to implement the seven other process modules, with reduced support, over the forthcoming months. Across NUH, wards are currently implementing 681 process modules. To fully maximise the benefits of the Productive Ward, wards need to complete all eight process modules and the three foundation modules. On average, for each of the 84 wards (excluding maternity) implementing the Productive Ward, the number of modules in progress is seven. Wards continue to demonstrate the increased uptake of modules. The Productive Ward is a long-term programme rather than a quick-win project and, as such, it will require ongoing project management and facilitated support within hospitals in order to achieve full benefit realisation and sustainable improvement.

The Productive Ward initiative has been designed to focus on ward teams and their processes and systems. It involves a multi‑disciplinary approach and teamwork so staff can understand and plan the most effective ways of delivering ward priorities. The programme equips staff at ward level with simple improvement methods that will enable them to develop well-designed systems and processes. These will release time so they can focus on aspects of care that impact on the patient’s experience and that improve patient safety and staff morale.       

Staff report good levels of satisfaction. For example, following implementation of the three foundation modules, staff feel that the changes have given the nursing staff more time with patients. Comments made by ward staff include the following:

• “the Productive Ward idea is very good but I think all staff should work on keeping things where they are. A better organised workplace gives us less stress to find things. We will try to be the best ward”
• “we have commenced Productive Ward and positive changes are happening to areas in regard to tidiness”
• “the ward is sometimes clean, dependent on who is working. Some people clean more than others and see the bigger picture and what is needed to do to keep it clean, so it should be more of a group thing rather than particular people doing more than their share. I feel that the Productive Ward has been a good experience and the ward is so much cleaner and organised but everybody needs to tidy up”.

Initially, the Productive Ward is concerned about the implementation of the modules from the NHS Institute. However, the vision is now to ‘change the way that nurses think’ to allow them to use skills to improve the services and experiences patients receive. It is intended that the Productive Ward will be made part of mainstream service improvement activity that every nurse can be involved in. If every nurse implemented one idea, the transformation to care would be tremendous. These ideas can be linked to trust objectives by delivering key organisational changes through the Productive Wards, which enable nursing staff to change how they care for patients. Unfortunately, nursing staff can at times complain about the challenges they face. This is not new: Florence Nightingale is quoted to have said, “I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results”.

The Productive Ward is a structured service improvement system launched by the NHS Institute that is focused on improving key activities at ward level. The Productive Ward is a long-term, ongoing programme and should not be viewed as a short-term fix. It will require personal commitment both from ward staff and the Executive Team. Ward staff have already made significant progress and have shown high levels of engagement with the Productive Ward. The Productive Ward programme is aligned with other key initiatives within the trust.  

This project undoubtedly reduces the amount of time ward staff spend doing tasks unrelated to patient care, for example looking for ward keys. It has greater benefits in helping to produce a cultural change in how wards use their specialist knowledge to improve the quality of their services for patients. The aim of this initiative is not to reduce nursing or workforce numbers. The aim is to give nurses back the time they need to attend to basic but vitally important patient care. This includes time to adequately communicate with patients while meeting their daily needs such as assistance with feeding and supporting families and carers.

1. Womack J et al The machine that changed the world. New York: Rawson Associates, 1990.
2. Womack J, Jones D. Lean thinking: banish waste and create wealth in your corporation. New York: Free Press Business, 2003. 
3. Jones DT, Mitchell A. Lean thinking for the NHS. An NHS Confederation leading edge report. Ross-on-Wye: Lean Enterprise Academy, 2006.
4. Miller D. Going Lean in Healthcare. www.wsha.org/files/82/GoingLeaninHealthCareWhitePaper.pdf (accessed 2 March 2012).
5. NHS Institute for Innovation and Improvement. Releasing time to care: the Productive Ward – box set. NHS Institute for Innovation and Improvement, Version 3, May 2008 (available to NHS trusts through the NHS Institute).
6. NHS Institute for Innovation and Improvement. Releasing time to care: the Productive Ward. The prototype development phase. Participant information. Coventry: NHSI, 2007.
7. Evans R. Releasing time to care: Productive Ward, survey results. Nursing Times 2007;103(16)(Suppl): S6–9.