By adopting techniques used in the car industry, the UK’s National Health Service has managed to cut down on nurses’ time, while also enabling them to work more safely, simply by measuring their tasks and analysing what they do
Kristy Parnell
Associate,
The Productive Series,
NHS Institute for Innovation and
Improvement
The ‘Productive Series’ is an educational initiative – from the UK’s National Health Service (NHS) Institute for Innovation
and Improvement – that has supported NHS teams since 2007, helping them to redefine and streamline the way they manage their work. By working with NHS front-line teams we have adapted efficiency and safety techniques previously used in car manufacturing and made them accessible to NHS staff in a practical and innovative way. This helps them to achieve significant and lasting improvements – predominately
in the extra time that they are able give to patients – as well as improving the quality of care they deliver.
Teamwork intrinsic to change
The success of the Productive Series is dependent on each person in the team being involved at every stage. The process they go through creates and promotes a continuous improvement culture leading to real savings in materials and a reduction of waste. It also has an impact on how they feel about their work and leads to a improved morale – because the staff are an intrinsic part of that change, contributing to it and ‘owning’ it. The improvements are driven by staff themselves, using tools and techniques which help them save time and resources when carrying out tasks. It encourages front-line staff to become critical practitioners, ask difficult questions about practice and influence the way they work.
Structured, practical methods
The ‘Productive Ward’ – one of the programmes in the series – recognises that nurses join the profession primarily to care for patients. Its purpose, therefore, is to equip ward leaders and teams with structured, practical methods to improve their ward environment, processes and systems. Improved processes can release time which can be redirected towards the patient, thereby improving the safety, quality and reliability of care – as
well as increasing patient and staff satisafaction. The aim is to help change the way that nurses think about everyday tasks and responsibilities, and to allow them to use their own perception and innate skills to improve services and patient
experience. We believe the ‘Productive Ward’ should be part of mainstream service improvement activity.
Modular, flexible and self-directed
The ‘Productive Ward’ is a modular, self-directed learning package designed to develop sustainable changes to ways of working, and create a culture of continuous improvement. The box set contains a ward leaders’ guide, three foundation modules, eight process modules and a toolkit. Executive sponsorship and project management are essential to successful implementation. The leaders guide outlines the basic principles of the programme as well as describing the time and resources requirements. It also suggests aligning the programme with the organisation’s strategic goals, and advises the executive sponsor on the behaviours needed to empower staff at ward level. Ward teams initially work through the foundation modules. The first of these, ‘Knowing How We Are Doing’ (KHWD), helps teams to examine what is happening on their ward. Ward teams collect baseline data relating to their current performance and identify what measures they will use to drive improvement and performance. The measures are displayed on a KHWD board and teams regularly meet to discuss what actions should be taken. Information about performance is easily accessible to clinical staff to check their performance, track improvements and plan for future improvement.
Kerry Bloodworth, assistant director of nursing at Nottingham University Hospitals, says that the ‘Productive Ward’ has provided staff with real time information that they own. “It has led to better observation of patients and better detection
of deteriorating patients. Visual display in wards of infection control, pressure sores and ‘fall’ data over time has helped staff to focus on how they are doing and to provide reassurance
for patients.”
Small changes can make a big impact
Small changes which may appear insignificant can make a big impact on the unproductive use of a nurse’s time. The Isle of Wight Hospital’s medical admissions unit reported a time saving
of 36 hours a year just by changing the location of frequently used equipment.
The ‘Well Organised Ward’ module helps teams look at improving their working environment, such as making sure the location of equipment and levels of stock help rather than hinder delivery of patient care.
At Central Manchester and Manchester Children’s University Hospitals NHS Trust, according to assistant director of nursing Dawn Pike, implementation of the ‘Productive Ward’ across 35 wards has increased direct care time by 12% – that translates
to 86 minutes in every 12-hour shift. She says: “One of the big hits at the beginning of Productive Ward is reorganising the ward environment. Just knowing where to find something improves patient safety.”[1]
Signposting progress
The final foundation module is ‘Patient Status at a Glance’ (PSAG). Teams develop PSAG boards which show where patients are in their care journey. By adopting visual management techniques and principles – such as the ‘three-second rule’ – teams can reduce the amount of time spent interrupting each other or searching for information. David Erskine Ward at Chelsea and Westminster Hospital, London, reported a time saving of over 30 hours per week through the introduction of a PSAG board and changing the location of shift hand-over from a seated meeting in the office to a standing meeting at the actual board. Once teams have set the foundations for change, they focus their new skills on the process modules – improving routine processes on the ward such as meal delivery, medicine and ward rounds, patient observations, patient hygiene, admission and discharge planning, nursing procedures and shift handovers.
Commitment to sustainability
Initial progress through the modules takes between 1-2 years. All the modules within the Productive Ward programme follow the improvement cycle (Prepare, Assess, Diagnose, Plan, Treat and Evaluate) and Ward Leaders are encouraged to follow this too. Ward teams need time to progress through the modules to ensure that the changes are adequately thought through and sustainable. The aim of each module is to improve the process and the care given, but just as important is the development of a new mindset, a new set of behaviours and the skills and confidence with new tools and techniques. Angie Braley, a
Ward Sister at Nottingham comments,”my ward has more or less ‘finished’ Productive Ward. We’ll revisit from the start though, because what I have found is that with all the changes we’ve made staff expectations have risen significantly
and now they want to do things even better”.
Benefits
With over 60% of NHS hospitals implementing the programme in England, improvements at ward level have become almost too numerous to list individually. The London Strategic Health
Authorities’ evaluation notes that ‘Productive Ward: Releasing Time to Care’ has been a significant catalyst for change and has resulted in measurable, positive impacts of:
- 13% increase in median direct care time.
- 7% increase in median patient satisfaction scores.
- 23% increase in median patient observations.
Productive Ward has been praised “for transforming healthcare – the scheme helps nurses spend an extra 500,000 hours with patients in one year. This equates to having an extra 255 full-time nurses … an equivalent level of service improvement
without the programme would cost an estimated £7.5 million a year”.
In practice
The acute long stay orthopaedic ward at Portsmouth City Hospital reduced incidents of pressure sores from 3-4 per month to zero and has sustained this for over ten months. The Royal Wolverhampton Hospital NHS Trust to date has released almost 7,000 hours of time to care for patients (187 working weeks).
At Nottingham, they have implemented ‘Productive Ward’ across 66 wards, with a total of 368 modules completed or in progress. Some wards are reporting an increase of 60% in time spent with patients.
Europe and beyond
Our NHS partners in Scotland, Wales and Northern Ireland have now bought licences to use the ‘Productive Ward – Releasing Time to Care’ and other ‘Productive’ programmes. In Europe, the Netherlands have plans for implementation and a
leading Danish hospital organisation is planning to pilot the programme on its wards. Outside Europe, the ‘Productive Ward’ has also had great success: two Canadian Health Improvement organisations are rolling it out in their provincial health care systems, district health boards in New Zealand and hospitals in
Australia are also implementing the programme and the New Zealand Ministry of Health has communicated its desire to roll out ‘Productive Ward’ to cover every acute bed in the country.
The NHS Institute’s evaluation of the ‘Productive Ward’ was launched by Chris Beasley at the Chief Nursing Officer Conference in late 2009.
References
1. Pat Anderson. The Productive Ward and it’s effects on patient safety. Health Care Risk Report Nov 2009. Nursing Management Journal 2009.
