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NIHR Signal Impact of a national quality improvement programme for hospital wards is unclear

Published on 22 January 2020

doi: 10.3310/signal-000862

The Productive Ward quality improvement programme has shown some procedural changes on hospital wards in England in the 10 years since it was introduced. But evidence to show any sustained changes to the experiences of staff or patients is hard to find.

This NIHR-funded study used quantitative and qualitative methods to evaluate the programme in six acute hospitals in England. It found some evidence of a lasting impact, such as wards continuing to display metrics and using equipment storage systems. But most hospitals that adopted the programme had stopped using it after three years, often due to a change in their approach to quality improvement.

Productive Ward resources are still available from NHS England’s Sustainable Improvement team, but are under review. This evaluation may be helpful in designing future similar schemes.

Share your views on the research.

Why was this study needed?

‘The Productive Ward: Releasing time to careTM’ was a quality improvement programme developed by the NHS Institute for Innovation and Improvement (NHSI) and introduced in 2007. It was designed to improve efficiency, productivity and performance at ward level in acute hospitals.

It was based on three principles:

  • good ward organisation so that materials were readily accessible
  • displaying ward-level metrics such as patient safety and experience
  • use of visual aids to understand patient status at a glance.

It also included a number of modules covering hygiene, shift handovers and protected mealtimes. In 2008, based on promising evidence from early test sites, £50m was invested to implement the programme widely in the NHS.

By 2012, it had been implemented in over 70% of all acute wards in the UK. Several other countries also introduced it.

This study investigated whether Productive Ward had a sustained impact in the ten years after it was introduced.

What did this study do?

The study used several methods to retrospectively evaluate the impact of Productive Ward. The authors carried out two national online surveys, staff and public interviews, observations and document analysis.

One survey had responses from 56 directors of nursing, and the other included responses from 35 current or recent Productive Ward leads.

The researchers then carried out case studies in six acute trusts that adopted Productive Ward at different times. These included interviews with 88 staff, patient and public involvement representatives, and 10 ward manager questionnaires. They also undertook structured observations on 12 randomly selected wards and analysed relevant documents.

In addition, they conducted telephone interviews with 14 former Productive Ward leads.

The study relied on the participants’ recall of events over 10 years. Separating the impact of Productive Ward from other subsequent quality improvement initiatives was sometimes difficult.

What did it find?

  • The surveys confirmed the rapid adoption and implementation of Productive Ward in England with most trusts starting in 2008-09, using a phased approach. Full roll-out was reported in 74% of cases. No trusts started using Productive Ward after 2012. Early adopters had access to more resources for supporting implementation.
  • Productive Ward is no longer systematically being used as a quality improvement tool in most trusts in England. Most trusts have stopped financial and management support for Productive Ward and 61% of the directors of nursing report that it is no longer regularly used. The average length of Productive Ward use was three years (range less than one to seven years).
  • The most commonly given reason for stopping Productive Ward was a change in the trust’s quality improvement approach, but Productive Ward leads in 97% of trusts (32 out of 33) reported that some elements were still being used. In all case studies, there was evidence of some material legacies, such as displays of metrics and equipment storage systems. However, these were not always being used appropriately. Some processes, such as protected mealtimes, were also still in evidence. The authors found that Productive Ward tools were rarely used to identify problems and potential solutions on an ongoing basis.
  • There was little evidence of Productive Ward transforming processes on hospital wards in the decade since it was introduced. In three of the six case studies, there was some evidence of it being customised or adapted into routine practices. But in the other three, Productive Ward was found to have been adopted only superficially, with little change to the functioning of the wards.
  • About one-third of trusts had impact data relating specifically to Productive Ward. Only one case study site had data collection systems that were robust enough to allow an objective assessment of the programme’s impact. In that site, care processes had improved initially, in terms of patient observations and direct care time. But there was no association with patient satisfaction.

What does current guidance say on this issue?

There is no national guidance on implementing and evaluating quality improvement initiatives. NHS Employers published a briefing in 2017 on staff involvement and quality improvement, which says that staff engagement is an essential part of a sustainable approach to quality improvement.

What are the implications?

This study did not find any lasting practical benefit from the Productive Ward quality improvement programme. Some ward practices and processes remained, but there was no evidence of their impact on staff or patients.

NHS England’s Sustainable Improvement team has been reviewing the NHS Productive Series, of which Productive Ward was one initiative. The findings from this study should help to inform the design and delivery of future programmes.

Future prospective evaluations of initiatives could avoid some of the inherent limitations of this retrospective evaluation.

Citation and Funding

Sarre S, Maben J, Griffiths P et al. The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study. Health Serv Deliv Res. 2019;7(28).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 13/157/44).

Bibliography

Morgan-Cooke, M. Reviewing the Productives – what we’ve learned. Leeds: NHS England; 24 May 2019.

NHS Employers. Staff involvement, quality improvement and staff engagement: the missing links? Briefing 110. London: NHS Confederation; 2017.

NHS Improvement. Releasing time to care, the NHS Productive Series. London: NHS Improvement; accessed 12 September 2019.

Why was this study needed?

‘The Productive Ward: Releasing time to careTM’ was a quality improvement programme developed by the NHS Institute for Innovation and Improvement (NHSI) and introduced in 2007. It was designed to improve efficiency, productivity and performance at ward level in acute hospitals.

It was based on three principles:

  • good ward organisation so that materials were readily accessible
  • displaying ward-level metrics such as patient safety and experience
  • use of visual aids to understand patient status at a glance.

It also included a number of modules covering hygiene, shift handovers and protected mealtimes. In 2008, based on promising evidence from early test sites, £50m was invested to implement the programme widely in the NHS.

By 2012, it had been implemented in over 70% of all acute wards in the UK. Several other countries also introduced it.

This study investigated whether Productive Ward had a sustained impact in the ten years after it was introduced.

What did this study do?

The study used several methods to retrospectively evaluate the impact of Productive Ward. The authors carried out two national online surveys, staff and public interviews, observations and document analysis.

One survey had responses from 56 directors of nursing, and the other included responses from 35 current or recent Productive Ward leads.

The researchers then carried out case studies in six acute trusts that adopted Productive Ward at different times. These included interviews with 88 staff, patient and public involvement representatives, and 10 ward manager questionnaires. They also undertook structured observations on 12 randomly selected wards and analysed relevant documents.

In addition, they conducted telephone interviews with 14 former Productive Ward leads.

The study relied on the participants’ recall of events over 10 years. Separating the impact of Productive Ward from other subsequent quality improvement initiatives was sometimes difficult.

What did it find?

  • The surveys confirmed the rapid adoption and implementation of Productive Ward in England with most trusts starting in 2008-09, using a phased approach. Full roll-out was reported in 74% of cases. No trusts started using Productive Ward after 2012. Early adopters had access to more resources for supporting implementation.
  • Productive Ward is no longer systematically being used as a quality improvement tool in most trusts in England. Most trusts have stopped financial and management support for Productive Ward and 61% of the directors of nursing report that it is no longer regularly used. The average length of Productive Ward use was three years (range less than one to seven years).
  • The most commonly given reason for stopping Productive Ward was a change in the trust’s quality improvement approach, but Productive Ward leads in 97% of trusts (32 out of 33) reported that some elements were still being used. In all case studies, there was evidence of some material legacies, such as displays of metrics and equipment storage systems. However, these were not always being used appropriately. Some processes, such as protected mealtimes, were also still in evidence. The authors found that Productive Ward tools were rarely used to identify problems and potential solutions on an ongoing basis.
  • There was little evidence of Productive Ward transforming processes on hospital wards in the decade since it was introduced. In three of the six case studies, there was some evidence of it being customised or adapted into routine practices. But in the other three, Productive Ward was found to have been adopted only superficially, with little change to the functioning of the wards.
  • About one-third of trusts had impact data relating specifically to Productive Ward. Only one case study site had data collection systems that were robust enough to allow an objective assessment of the programme’s impact. In that site, care processes had improved initially, in terms of patient observations and direct care time. But there was no association with patient satisfaction.

What does current guidance say on this issue?

There is no national guidance on implementing and evaluating quality improvement initiatives. NHS Employers published a briefing in 2017 on staff involvement and quality improvement, which says that staff engagement is an essential part of a sustainable approach to quality improvement.

What are the implications?

This study did not find any lasting practical benefit from the Productive Ward quality improvement programme. Some ward practices and processes remained, but there was no evidence of their impact on staff or patients.

NHS England’s Sustainable Improvement team has been reviewing the NHS Productive Series, of which Productive Ward was one initiative. The findings from this study should help to inform the design and delivery of future programmes.

Future prospective evaluations of initiatives could avoid some of the inherent limitations of this retrospective evaluation.

Citation and Funding

Sarre S, Maben J, Griffiths P et al. The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study. Health Serv Deliv Res. 2019;7(28).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 13/157/44).

Bibliography

Morgan-Cooke, M. Reviewing the Productives – what we’ve learned. Leeds: NHS England; 24 May 2019.

NHS Employers. Staff involvement, quality improvement and staff engagement: the missing links? Briefing 110. London: NHS Confederation; 2017.

NHS Improvement. Releasing time to care, the NHS Productive Series. London: NHS Improvement; accessed 12 September 2019.

The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study

Published on 19 August 2019

Sarre S, Maben J, Griffiths P, Chable R & Robert G.

Health Services and Delivery Volume 7 Issue 28 , 2019

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.

Author commentary

The long-term sustainability of quality improvement programmes is rarely studied. This programme aimed to help ward staff run their hospital wards more efficiently and give them more time for patient care.

It found that the programme appeared to work best when all levels of ward staff were involved in generating ideas and carrying out the improvements. Good communication with central services, like catering and supplies, was also important.

Where staff had been given a real understanding of the underlying principles of quality improvement they were able to build on their earlier work over time, as new challenges and possibilities arose.

Dr Sophie Sarre, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London