The Productive Ward Portsmouth Hospitals NHS Trust “Drowning in service improvement initiatives” The sheer number of different service improvement programmes available to NHS organisations can be overwhelming, and trying to implement several different initiatives simultaneously presents a real challenge. Portsmouth Hospitals NHS Trust has taken a pragmatic approach. Rather than attempting to implement different improvement initiatives which include The Productive Ward, the High Impact Actions, Essence of Care, Energise for Excellence and Portsmouth Hospitals own Values, the Trust has taken The Productive Ward as its core framework and “bundled together” relevant components from other improvement programmes. It has created a tailored programme that links elements of the different initiatives, with the aim of delivering the very best experience for patients.
Focusing on quality Portsmouth Hospitals Deputy Director of Nursing, Nicola Lucey explains: “There were so many different initiatives that the wards were potentially drowning in service improvement programmes. There is a great deal of overlap so we decided that bundling initiatives together was the best way of taking this forward and giving the wards some control back. For example, we joined up Ready to Go No Delays with the Admissions and Planned Discharge module in The Productive Ward. We anticipate this will deliver a significant improvement in efficiency. “If you focus on quality, the efficiencies will fall out of that. The best evidence around Energise for Excellence, Essence of Care, High Impact Actions and The Productive Ward shows that if you ensure you are delivering safe, quality care at the right time for the patient, you will automatically achieve savings by cutting things like length of stay and preventing avoidable harm. We estimate, for example, that The Productive Ward has the potential to make a 15% contribution to length of stay savings.” (Rapid Impact Assessment of The Productive Ward, NHS Institute for Innovation and Improvement, 2011)
Sustained improvement Portsmouth Hospitals NHS Trust first began The Productive Ward programme in 2007 as one of the original test sites. Then, in 2009, the Trust merged three hospital sites onto one main site. The Trust was in Turnaround, having failed to meet financial and other targets. Different wards were at different stages of The Productive Ward and some teams that had worked together on the programme had been split up. Sustained improvement was needed, so the executive team decided to re-launch The Productive Ward, incorporating key elements of other programmes. The new programme was launched in September 2010.
A flexible approach Practice Transformation Facilitators, Caroline Churcher and Claire Dyson, supported the rollroll out of The Productive Ward in Portsmouth and created a week-by-week week week plan for wards to follow. Claire comments: “We decided to take a Trust-wide Trust wide approach and bring everyone to the same starting point. We held a series of open days and training events prior to the launch in September. The programme began with the three Foundation modules, Knowing How We Are Doing, Well Organised Ward and Patient Status at a Glance (PSAG) across 41 separate wards. Although Caroline and I facilitate the process, it is very much the wards’ programme and we are developing the leadership of ward managers and teams to be able a to manage their own programmes. “The work is not set in stone. We review each ward every 30 days to see how they’re doing and we can adapt the programme as we go, if we need to. For example, at times of peak demand, we have extended the time available to teams to complete core tasks. It is a flexible process. Each team is getting to the same point at roughly the same time, but the journey they take is very different.”
Benefitting from “Bundling” Sue Sylvester is a Ward Manager with experience both of the previous approach to The Productive Ward and the subsequent “bundling” approach. She admits to having reservations about the idea of incorporating elements from other service improvement initiatives at the start: “We had a huge amount of resource when we began The Productive Ward in 2007 – protected time, backfilling the shifts of particular members of staff, things like that. Without that sort of resource, I thought “this isn’t going to work”. But, I have completely changed my point of view. In fact, I wish we’d done it this way before. There is a real momentum and the buzz from the wards is palpable. Teams are keen to start working on the next modules as they can really see the benefits of the work they’re doing. I am so pleased to have been proved wrong. ng. My advice to anyone considering this way of doing service improvement is seize it by the horns and go with it, because it works!”
Reducing length of stay tay Deborah Hutchinson is Head of Turnaround at Portsmouth Hospitals. She explains how the Trust is using The Productive Ward as an enabler tool to contribute towards the Trusts overall length of stay reduction. “There were four components to this: we needed to ensure that we had the right beds in the right place; we needed to look at reducing length of stay for specific high risk groups; we needed to streamline our complex discharge process so that we could get patients discharged more quickly; and we needed to have a predicted date of discharge for every patient.
Following previous Productive Ward launches launches the Trust Turnaround board facilitated the PMO to support the fast-track track introduction of the Patient Journey whiteboard across the Trust. Whereas previously patient record boards had been used to record what had been done for the patient, the emphasis now is on using it to plan what needs to be done. A predicted discharge date is set within 24 hours of admission and there is a traffic light system to identify potential delays, so that staff can take proactive steps to speed things along. We introduced a weekly audit to ensure that wards were using the new boards correctly. The value of the boards is that they make the status of individual patient’s visual to staff; they can see potential problems that could delay discharge and, if possible, do something about them. The Patient Status at a Glance, which was part of the turnaround project, has helped achieve a marked reduction in the length of stay of -0.4 0.4 average days in elective and -0.2 0.2 average days in non-elective elective over a twelve month period. The Trust is using four key metrics to track the reduction in length of stay. tay. It is tracking length of stay tay by ward and for patients who are in hospital for 14 days or more. It is also tracking how many patients are discharged on their predicted date and the the reduction in bed numbers. The next stage is to rebalance the distribution of beds according to patient need as well as introducing a flexi bed model to cope with peaks in demand.
Planning patient care Mandy Houghton, Sister in the Head and Neck Unit comments: comments: “The Patient Journey board charts a patient’s journey through the hospital, showing when they are likely to be going home and what has to be done before they are discharged, discharged any variation to the plan is written in red. The entire multi-disciplinary multi y team can see what needs to happen and whether we are on schedule to discharge the patient as planned. Before we had the boards, staff would have had to find the nurse in charge for a detailed summary of the patient’s treatment. This approach saves time. We now have a 21 day planner, rather than the standard seven days, so we no longer have to wipe everything off the board after seven days and start again for longer stay patients. We can track patients over a longer period and plan ahead more effectively.” The boards on the wards inspired the Medical Assessment Unit to create their own medical handover board where they include information about whether the patient has been assessed and if they are fit to be moved or ready to go home. Dr Mike Bacon is Clinical al Director of Acute Medicine. He comments: “We have 49 care spaces on the unit, spread over four geographical areas, so trying to monitor what is going on across the unit can be difficult. Senior doctors meet at the board at 11.45am 1.45am every day to go through the 49 patients. It allows us to keep track of exactly what is going on and anticipate how many patients might be going home that day. We can also feed back to our specialist colleagues how many beds we are likely to need for patients requiring further treatment. The patients benefit from a smoother journey, with less repetition and fewer delays. For the nurses, it is a way for us to communicate with h them what the medical thinking is behind individual patient treatments.”
Reinvesting time saved The Productive Ward is described by Portsmouth Hospitals as “an enabler” to help it achieve an improved patient experience and greater efficiencies across the the service. Both staff and patients are benefitting from the changes that are being made across the Trust, as the experience of Sue Metcalf, a Matron, demonstrates. Sue has been able to reinvest the time saved as a result of completing The Productive Ward into registered nurse assessments. She explains: “There was anxiety from staff about where we would be able to find the time to do all of the assessments. By refining our core processes using The Productive Ward, and through the time savings that have been achieved as a result of our work on the Well Organised Ward module, we have been able to focus on registered nursing assessments. In a pressurised, high speed environment, it is valuable for staff to have an opportunity to pause and re-examine examine their working worki practices. For patients, the focus of nursing assessments means that staff are monitoring their progress more closely and are vigilant about the risk of things like pressure ulcers and falls.”
Executive support Strong executive support has been the key to the success of The Productive Ward at Portsmouth. Julie Dawes, Director of Nursing, explains: “To make this work, you need sustained senior level support. Our executives have a good understanding of what the programme ogramme is and what it is trying to do. They provide visible support and encouragement to programme leaders, for example, by doing executive walkabouts. We go out and talk to staff about how the programme is helping them – this is how we communicate the benefits nefits from ward to Board.”
Making QIPP real Julie Dawes, Director of Nursing, sums up the impact that The Productive Ward is having in Portsmouth: “The Productive Ward is a really important tool for improving quality and productivity. It’s about getting local ownership for patient safety, patient experience and patient outcomes at work level. People put the projects together themselves so there is a real sense of local ownership. It makes the whole of QIPP real for nursing staff.”
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The Productive Ward Portsmouth Hospitals NHS Trust case study