A pilot for change in a productive ward

The productive ward series is an initiative, developed by the NHS Institute for Innovation and Improvement, and launched in the UK in 2007. It aims to motivate and cultivate healthcare teams to redesign and streamline the way in which activities are undertaken in the workplace. 

The goal for change is to increase the amount of time spent providing direct patient care and improving efficiency in the clinical areas. This initiative was introduced in Ireland in 2010 by the Health Service Executive (HSE).

In 2012, the Rotunda Hospital was invited by the HSE to be one of the pilot sites. The Rotunda is a tertiary referral centre, that serves a mixed population from Dublin city and the surrounding areas. The primary focus of the adoption of this pilot was to increase direct patient care in order to add quality to patient experience and increase staff job satisfaction.

The Lillie Suite (postnatal ward) was selected by the hospital executive management team to participate in the pilot programme. The ward has a capacity for 29 beds, providing postnatal care for mothers attending the public, semi-private and private obstetric service. The vision of the ward is aligned with that of the organisational strategic plan: to continually improve and enhance patient experience and to provide a safe and supportive environment for all patients during their transition to parenthood.

The productive ward ethos is based on the ‘lean’ principles used in manufacturing industries. Lean is described as a reference-sustainable method to improve the quality, cost-effectiveness and delivery of goods and services. The programme draws on the ‘Lean Thinking’ principle of reducing activities that do not add value. 

Many organisations are adopting these principles as a vehicle for continuous improvement. This methodology is also associated with ‘High Quality Care for All’¹, which sets out a new foundation for a health service that empowers staff and gives patients more choice. 

Commencement of pilot

The productive ward programme is based on a number of foundation modules and a toolkit is available through the HSE. Training, based on ‘Lean’, was provided for the frontline staff on the ward including the clinical manager, midwives, catering and household staff, and ward clerk. 

The aim of the training programme was to empower the team to identify areas on the ward for improvement by giving staff the information and skills they needed to make the necessary changes for success. 

Team meetings were organised and a plan of action developed on how change could be initiated. The team leader submitted a proposal and ward vision to the hospital executive management team, who were very receptive and supportive; this provided the encouragement needed to commence the journey.  

Communication was a key factor for success and to ensure the relevant information was made available for all staff. An information stand was set up specifically for the project so that all staff were involved. Each step was outlined to ensure the information was understood and could be acted on.

During the initial training, the staff were advised that their first project should be simple, realistic, of short duration and achievable, with ease for a quick win. This worked to motivate the team to take on other modules.

WOW module

The Well-Organised Ward (WOW) module involves a series of actions that help create an ideal workplace by organising, cleaning and reducing waste, known as the five ‘S’s: 

• Sort: remove what is not needed
• Set: right thing in the right place
• Shine: keep things clean and ready to go
• Standardise: an agreed, consistent process
• Sustain: continually audit and improve. 

The five ‘S’s are not about just having a good tidy up, but having a ward where equipment and stores are immediately made ready for the next person. The process for doing this is agreed and understood by everyone on the ward and changes are maintained once they have been implemented until they become second nature to the staff.  

There is also the option to go back and make further changes when things still are not quite right. In this way, staff begin to understand why things are done the way they are done. 

By completing the five ‘S’s it was possible to see changes to the workplace environment, which gave ownership to the staff. In addition, staff were made aware of the cost of all stock items in the ward, excess stock was recycled and an agreed stock level set. This resulted in a clutter-free store room, less waste and more time spent with patients. An additional bonus was cost savings to the ward.

Information on the module ‘Knowing how we are doing’ was obtained by undertaking patient and staff satisfaction surveys. The findings of these surveys gave direction for ongoing improvements. In order to be able to measure improvements, a number of tools were devised to collect relevant data to sustain ongoing change. 

By using the tools, it became apparent if, and what, corrective action was required. In addition, it gave staff a reason to celebrate as goals were achieved. Nonetheless, the introducing the pilot does not come without its challenges: the main barriers are staffing levels, high patient activity, staff buy-in and time.  

The team leader needs to be able to generate enthusiasm on an on-going basis. To overcome the challenges, regular updates on the productive ward’s progress should be communicated to the team, which in turn helps to attract more buy-in and team commitment. 

The results of the pilot phase were:

• Direct patient care increased by 15%
• Staff job satisfaction increased by 7%
• Cost savings in general stores and pharmacy achieved
• Catering service revamped for patients, leading to improved quality of food and  healthier menu options
• Better organised ward and equipment easily located, making a more user-friendly environment for staff
• Time taken for handover reports reduced by 10 minutes daily
• Up to 60% reduction in interruptions after introduction of patient information board and improved signage.

Embracing change and sustainability

Like any change, the productive ward is a constant process that needs to be embraced as part of daily activity. As health service care providers the struggle is ongoing to bring about innovative changes and improvements in the current healthcare setting. 

Productive ward is often challenging as we try to embed new habits and working practices within minimum resources and it is an uphill battle for sustainability. However, it is important not to get frustrated and lose sight of the goals set. We have found that when a deadline is not met, it is possible to move the time limit, provided there is still some flow of activity.  It is a matter of adjusting expectations; there are times when a pause is required before introducing a new module.

The productive ward programme is a useful driver for improvement, which can be adapted for use in multiple healthcare settings. To work well a champion is required; this can be the ward manager or an interested staff member who can continuously motivate other staff. To make it work, it is important to set realistic goals and time scales and to know that activities can be linked to everyday work. 

Support from senior management is essential for a successful outcome. The initial findings of our pilot, have shown that Productive Ward is a programme you cannot afford to overlook if you are serious about embedding improvement capability into everyday work in the clinical areas. It is also key to the provision of quality care in recessionary times. 

References

1. Department of Health, High Quality Care for All: NHS Next Stage Review Final Report. London: DH, 2008
2. Miller, D. Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement, 2005
3. NHS Institute for Innovation and Improvement. Releasing Time to Care: The Productive Ward. The Prototype development phase. Participant Information. Coventry: NHSI, 2007
4. The Productive ward series. Available at: http://www.hse.ie
5. Stella W, Wilfred Mc Sherry. A systematic literature review of Releasing Time to care: The Productive Ward. J Clin Nursing 2013; doi: 10.1111,1-11
6. Releasing Time to Care: The Productive Ward Module boxed set NHSSIPW book set. Institute of innovation and improvement, 2008