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Reinventing the Productive Ward: what nurses need from a quality improvement toolkit

Ten years ago the programme was all the rage, and now it’s set for an update 

Ten years ago the programme was all the rage, and now it’s set for an update

  • Study examining the effectiveness of the programme finds widespread uptake but mixed results
  • NHS England is developing an updated version of Productive Ward, based on feedback from ward leads, staff and patients
  • Nurses involved in the Productive Ward ‘get’ lean ways of working

Shift handovers was one of Productive Ward’s most successful modules Picture: John Houlihan

A decade ago, it seemed that almost every ward had a nurse busily sorting and colour-coding the store cupboard, or plotting the routes that staff took as they did the drugs round.

These activities, as many nurses will remember, were part of Productive Ward: Releasing Time to Care, a quality improvement toolkit launched in England by the NHS Institute for Innovation and Improvement in 2007.

A programme to improve ward efficiency

Productive Ward was intended to give ward staff the tools, skills and time needed to implement local improvements, increase the time they spent on direct patient care, improve the safety and reliability of care, improve the staff and patient experience, and make structural changes on wards to improve efficiency.

The self-directed toolkit consisted of three foundational modules – ‘Well-Organised Ward’, ‘Knowing How We are Doing’ and ‘Patient Status At a Glance’ – and eight additional modules dealing with specific ward processes, including shift handovers, meals and medicines rounds. 

By 2012, 70% of acute wards in the UK were reported to be using the programme. Conferences and journals were full of nurses talking about their experiences of implementing the programme in their workplace, which included the time staff had saved by ensuring protected meal times or not having to hunt about for a dressing in a messy stockroom.

The success of the programme spawned a whole ‘Productive’ series, including editions for mental health wards, leaders, operating theatres and community services.

Researchers examine the impact of Productive Ward

Ten years after the programme was launched, a research team led by King’s College London (KCL) began a two-year study that examined whether there was a lasting impact from the approach. 

Findings from the study are being used by NHS England to develop a new version of Productive Ward, which is expected to be published by the end of this year. NHS England says the updated toolkit will focus on the ‘challenges the NHS faces today’. 

‘Productive Ward... introduced many ward nurses to quality improvement approaches for the first time’

Sophie Sarre, research fellow at King’s College London

The study, funded by the National Institute for Health Research, included case studies from six acute trusts, surveys of 56 directors of nursing and 35 current Productive Ward leads, and interviews or questionnaires with staff members, patient and public representatives, ward managers and former Productive Ward leads. The researchers also carried out structured observations of 12 randomly selected wards.

Scheme got nursing staff a seat at the quality improvement table

The results show that the legacy and impact of Productive Ward varied between the trusts studied, and the researchers said there was a dearth of quality data that compared working practices before and after the scheme was introduced, which made it difficult to assess its impact.

‘Little robust evidence remains of Productive Ward leading to a sustained increase in the time nurses spend on direct patient care or improvements in the experiences of staff and/or patients,’ the report states.

However, the study found that the programme had created important and lasting change in at least some of the sites. ‘Productive Ward had a lot of success,’ says Sophie Sarre, a research fellow at KCL who led the study. ‘It got nursing staff a seat at the quality improvement table at board and ward level, and it introduced many ward nurses to quality improvement approaches for the first time.

‘On the wards it seemed to streamline processes and get care closer to the bedside, which was one of the important aims, such as by putting an observation machine in each bay.’

How will the updated Productive Ward be different?

NHS England is developing a refreshed version of the Productive series, which is expected to be published by the end of this year.

Researchers who studied the existing Productive Ward programme gave the following advice on how the new version should be different:

  • Think beyond the ward Although many nurses identified with Productive Ward, other staff groups were seldom engaged. It needs to recognise multidisciplinary teamworking and whole-system transformation
  • Resourcing It would require sufficient resourcing to release staff from ward duties. A dedicated member of staff to coordinate activities and training is another key factor to ensure sustained impact
  • Focus on quality not quantity Wards often tended to rush through the eleven modules, or would simply miss some out altogether. In some wards, ‘solutions’ were imposed by programme leads and/or ward managers without giving other staff enough opportunity to identify options
  • Less is more Productive Ward could be slimmed down. The most useful modules were the three foundation modules, followed by the medicines, patient observations and shift handover process modules. The remaining process modules were rarely implemented and could be omitted from the new version
  • Play the long game Systems for robust measurement of impact and costs should be built in from the start
  • Adaptability The programme needs to be able to absorb and adapt to changing organisational or NHS priorities
  • Involve patients and carers as partners

Source: NHS England and NHS Improvement

 

The legacies and learning from the programme

Successful legacies of the programme that could still be seen on many wards included protected mealtimes, more equipment kept closer to beds, and more efficient shift handovers.

An inpatient eating at the bedside. Successful legacies of the Productive Ward programme included protected mealtimes
Picture: Alamy

But the study also found chaotic mealtimes at some sites that had been through the Productive Ward programme, with dietary restrictions often recorded on more than one board and not regularly updated, and no systems for flagging missed meals.

There was also a lack of systems to record missed observations or medication.

Visual displays of data such as safety crosses and ‘Knowing how we are doing’ boards were often still present on wards, although some were not updated regularly, or were not relevant or discussed.

The study found the average length of the programme’s use in its case study sites was three years; financial and management support for the programme has disappeared in most trusts.

Investment and resources were key to programme implementation

Nurses surveyed for the study said it could be difficult to justify the resources needed for Productive Ward. ‘I couldn’t necessarily see the benefit,’ one nurse said.

Generally trusts said they no longer used the programme because they had adopted a different quality improvement (QI) approach, but the influence of Productive Ward was still felt in about half of the trusts’ QI strategies. Staff spoke about using Plan-Do-Study-Act improvement cycles, adopting a ‘lean’ mindset to reduce waste and improve patient flow, and giving ward staff a greater voice in QI.

‘It is apparent that those involved in Productive Ward ‘get’ lean ways of working’

Survey reposndent

One respondent said: ‘There are many similarities between the Productive Ward and the work we are now doing. Staff are not starting from the beginning, but building on work that has been done in the past. It is apparent that those involved in the Productive Ward ‘get’ lean ways of working and are able to grasp the principles easily.’

Nursing staff told the researchers about the major impact that being involved with Productive Ward had had on their careers. Starting with little or no QI experience, many went on to work on other initiatives at their trusts, or to work in QI at regional or national level in the NHS or the private sector.

Dr Sarre says the £50 million invested by the government to support the Productive Ward programme in England was essential to it being rolled out so widely. This money helped to fund Productive Ward leads, and money was used to release staff for training.

The study report says important lessons learned regarding local implementation at each trust included:

  • Integrating Productive Ward teams with the QI team.
  • Engaging central services and doctors from the start.
  • Training all levels of staff in the principles underlying the programme.
  • Achieving broad staff engagement with the initiative.

Organised work areas helped staff feel less tired

Peter Griffiths, chair of health services research at the University of Southampton, and one of the study’s researchers, agrees that the Productive series has had a major impact.

‘I would describe myself as a professional cynic, but when we were doing the research it did strike me how enthused people were. This has been embraced so positively. Productive Ward was very carefully designed, it was deliverable and well packaged.’


Productive Ward promoted efficient practices such as organising hospital supplies and spaces,
but financial support for the programme ran out in most trusts Picture: SPL

Liz Charalambous, an older people’s nurse and PhD student in Nottingham, can remember the enthusiasm the project inspired when Productive Ward arrived at the older people’s acute medical ward where she worked.

‘I found it very good, it was a sensible idea,’ she says. ‘It was good to spend some time on housekeeping and organise the work areas to minimise footfall, which helped nursing staff feel less tired. I derived great satisfaction from throwing away defunct equipment and out-of-date size 22 catheters.

‘Challenges included worries over landfill and environmental impact, finding nursing time to invest in the project as opposed to providing patient care, and the impact on estates and facilities, which needed careful managing.’

The programme led to tidier wards and an easier work environment for nurses, she says. ‘It paved the way for streamlining systems and processes, so maybe it did change practice long term.’ 


Erin Dean is a health journalist

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