NHS quality improvement programme’s legacy influenced by variations

Medical staff

The Productive Ward programme was introduced by the NHS as a quality improvement intervention.

The legacy of an NHS-led quality improvement programme – ‘Productive Ward: Releasing Time to Care™’ – has generally been positive since its introduction in 2007.

Now, a study on the programme’s 10-year legacy (2007-17) has found that its sustained impact has been strongly influenced by how implementation was resourced and executed and by the design of the programme itself.

Researchers from King’s College London, University of Surrey, University of Southampton and University Hospital Southampton NHS Foundation Trust have published the results of their two-year study, funded by the National Institute for Health Research (NIHR).

After surveying the Directors of Nursing in all acute Trusts in England and staff that currently or recently lead Productive Ward at Trust level, the researchers found significant variations in implementation that had important consequences for the sustainability of the programme over a decade. For example, over time it was less common to train and involve whole ward teams. Instead Productive Ward leaders and ward managers tended to execute ‘short cuts’ motivated by time constraints and a trust-level desire for standardisation.

The Productive Ward programme was introduced by NHS Improvement in English acute hospitals with government funding of £50 million as a quality improvement intervention which sought to help NHS staff to increase productivity and reduce waste, provide better quality, safer care and a better experience for patients and staff. The programme consisted of modules (e.g. well organised ward, patient status at a glance, meals and medicines), a toolkit and guidance, which sought to enable frontline staff in acute hospitals to take ownership of their ward and improve the ways in which it worked.

The focus of the programme was primarily on nurses, who – if working on a ‘productive ward’ – would, for example, streamline mealtime processes, improve the reliability of patient observations and reduce the time they spent fetching supplies, so they could spend more time with patients.

The study explored the timing of adoption, how Productive Ward was implemented, reported impacts, what happened to the programme over time, what legacies remained and what factors had helped or hindered sustainability. Interviews were also conducted with former Productive Ward leads and organisational case studies within six acute Trusts, which involved interviews with those involved in implementing Productive Ward; structured observations and questionnaires to ward managers on two wards at each hospital; and analysis of reports and outcome measures.

The study’s specific findings and implications include:

  • Productive Ward was seen to have led to positive change, during implementation, through more efficient and/or standardised routines; the display of information; rethinking processes; giving staff a voice; and improving staff knowledge and skills in quality improvement;
  • In all case study sites, material legacies (e.g. display of metrics data; storage systems) and some ward practices remained. However, in practice these did not always serve their original purpose well. For instance, safety incident and other ward-level data were not always up to date or on public display; and were often difficult to interpret, and rarely discussed with whole ward teams;
  • A significant proportion of Trusts reported regularly using some elements of the programme, and said it informed wider organisational quality improvement strategies that remain in place today;
  • Whilst evidence from the survey showed that the programme was overwhelmingly viewed as positive, for some specific aims (e.g. staff morale) a relatively high proportion of respondents noted no impact;
  • Only one Trust had robust outcome data over time, showing a modest improvement in time nurses spent directly caring for patients as wards progressed through the Productive Ward modules.

“The Productive Ward made a major impact when it was launched across the NHS over a decade ago,” said Professor Peter Griffiths, Chair of Health Services Research at the University of Southampton. “On one hand, it is disappointing that it has been so hard to measure lasting impacts but in a rapidly changing world the productive ward seems to have anticipated a lot of things that have now become mainstream and its legacy can be seen in a lot of common practices.

“It is perhaps time to revive the ‘spirit’ of the programme by revisiting how we can really free up health professionals to focus on the time they spend with patients to really add value to the care they give,” Professor Griffiths concluded.

NHS England plans to refresh and relaunch Productive Ward. In collaboration with NHS England, the research team have developed a set of recommendations based on their findings to help guide this national relaunch. Given the limitations of the existing evidence base, the researchers caution against a sole focus on the intervention’s potential for productivity improvements and efficiency savings. Rather, highlighting how staff and patient experience might be improved through implementation of a modified form of the Productive Ward is likely to be more engaging and – combined with more targeted and rigorous data collection – lead to a clearer business case for the programme. Any future similar programme should avoid a purely nursing focus and recognise the multi-disciplinary and whole hospital nature of contemporary service delivery. A focus on the three core modules and a much smaller number of process modules would facilitate implementation and sustainability in increasingly busy ward environments.

Lead author Dr Sophie Sarre from the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care at King’s College London said:

There is no doubt that with few exceptions, people who had been meaningfully involved in implementing Productive Ward were enthusiastic about its potential to release time to care. Key to sustainability were having the resources to engage and provide training to staff of all levels and disciplines in and beyond the ward. This instilled a Productive Ward mindset that meant that staff could continue to make improvements as contexts changed over time. A programme with fewer modules, at least initially, would help sustainability.

‘The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study’ is published in Health Services and Delivery Research by the National Institute for Health Research.