However, lack of funding, time constraints and interference from managers resulting in “short cuts” being made led to a watering down of the original vision of the “productive ward” scheme, UK researchers found.
“Over time we noted a shift away from a longer-term vision of empowering ward teams to take ownership”
Devised by the NHS Institute for Innovation and Improvement in England, the productive ward programme was first implemented in 2007 and went on to be rolled out across all acute hospitals backed by £50m in government funding.
The aim was to give nursing staff the tools, skills and time to make improvements in order to increase the amount of time nurses spent directly caring for patients, boost safety and reliability of care, enhance the experiences of both patients and staff, and make changes to the physical environment in hospitals to improve efficiency.
Researchers from the Florence Nightingale Faculty of Nursing and Midwifery at King’s College London, University of Surrey, University of Southampton, and University Hospital Southampton Foundation Trust set out to assess the impact of the programme more than a decade after it was introduced.
They used various research techniques to explore how the scheme evolved at six different hospitals including interviews with ward leads, staff, and senior managers, questionnaires completed by ward managers and observations on 12 wards.
Findings published in BMJ Quality & Safety suggest the productive ward scheme made a lasting difference but the extent of its impact locally depended on a range of factors including the amount of resources put into the scheme and the way in which it was implemented.
In each of the six hospitals they studied the researchers found some material aspects of the programme were still in place such as displays of ward data and safety incidents.
However, the information on show was often out of date, difficult to understand and “seemingly rarely discussed by ward teams”.
When it came to how the programme had influenced the way things were done, they found some specific practices that stemmed from the programme, such as systems for flagging up patients who had missed observations, were still in place on all 12 of the wards they visited.
However, three elements appeared to have fallen by the wayside entirely and were not evident on any of the wards. These included displaying a “ward vision” and an up-to-date chart setting out how often executive and senior staff would visit the ward to check on progress.
Ward managers reported several other standardised procedures were still in place such as equipment being in the right place and ready to use.
While productive ward resources and guidance were now “rarely used”, the study found those who had been actively involved in implementing the programme continued to deploy learning and key messages they had picked up such as a “plan-do-study-act” approach to improvement, having a “lean” mindset to reducing waste and improving patient flow, and the need to give ward staff a bigger say in quality improvement work.
Meanwhile, there was evidence the programme had helped boost quality improvement capabilities within hospitals as a whole.
Two hospital-wide quality improvement programmes – at least in part based on the productive ward scheme – were still in place while support and training based on the scheme was on offer to staff in three out of the six hospitals studied.
At one hospital the programme had led to the creation of a new “head of nursing for quality improvement” role and a central quality improvement team who delivered training.
Overall, the research team concluded the programme had brought about tangible and lasting change at two out of the six hospitals going on to become part of the day-to-day routine.
In two hospitals they found core elements and tools from the programme were “being used superficially, in a ritualistic way (if at all) with the functioning of the hospitals remaining largely unchanged”.
At the remaining two hospitals studied – where the programme was adapted significantly – the picture was less clear.
The researchers, who identified key differences in the way the programme was implemented between hospitals and often between wards in the same hospital, said their findings contained important lessons when it came to ensuring large-scale quality improvement programmes had a lasting legacy.
“These short cuts seemed to occur where there was conflicting rationales for the programme among different stakeholders”
Key issues included difficulties involving senior leaders and key members of staff, and short-term funding.
“The – typically – two-year time-limited availability of funding was usually insufficient to enable hospital-wide implementation in the way that was intended by its designers,” said the paper.
This was especially true in larger organisations with many wards, it added.
There were differences in the resources available to hospitals taking part, how the programme was led and managed locally, the training provided to staff, the way the programme was evaluated and the involvement of patients.
Researchers said there had been a noticeable move away from the original vision of frontline nurses “taking back control” and implementing changes themselves to a more “top-down” approach based on meeting targets.
“Over time we noted – both within and between our six hospitals – a shift away from a longer-term vision of empowering ward teams to take ownership of the programme towards a narrower, solely efficiency-based view of the goals of the productive ward,” said the paper.
This manifested itself “in a range of implementation ‘short cuts’ motivated by time constraints and the managerial desire for standardisation,” said the paper.
“These short cuts seemed to occur where there was conflicting rationales for the programme among different stakeholders: for example, where a managerial efficiency agenda took precedence over ‘releasing time to care’ on wards,” it continued.
“There was often tension between wards’ desire to find their own solutions to their problems and hospital managers’ desire for standard practices and infrastructure that made it easier for staff to work across a hospital and which could deliver economies of scale.”
For example, in one hospital which joined the scheme late on and the programme was “relatively under-resourced” ward teams were actually excluded from implementation. Instead “facilitators” did much of the work “including imposing ‘solutions’”.
“Where – as intended – whole ward teams had been trained in the principles underlying productive ward we found that staff continued to apply these principles to their quality improvement work even as organisational contexts changed over time,” said the paper.
Overall, the researchers concluded the programme had made a lasting difference with five out of the six hospitals studied showing “some form of sustained impact” over the last decade.
“However, as an ongoing quality improvement approach – continually used to identify and improve problem areas – productive ward has been less successful,” the paper said.
“The resources available at the point of adoption and the – closely related – issue of how the productive ward was then implemented locally, shaped the evolving forms of assimilation into routine practice over time; these and wider contextual changes largely determined the legacies of the programme.”