The Clinical Services Journal reports on The Productive Ward: Releasing time to care programme and looks at its successful implementation at Airedale NHS Foundation Trust, where is has helped to improve infection control rates and reduce medication errors.
As the focus on quality and efficiency becomes sharper in the NHS, ward teams need to ensure they are delivering the best possible patient care in the most productive and cost effective manner. The Productive Ward: Releasing time to care programme has been developed by the NHS Institute for Innovation and Improvement and co-produced with NHS organisations, to help ward teams identify significant improvements in productivity and efficiency by helping staff to create an environment where quality is maximised, processes are efficient and variation is minimal, and where patients feel safe and well cared for. The programme is currently being implemented in over 89% of acute Trusts across the NHS in England. Many organisations implementing the programme have already achieved significant benefits. By improving processes and efficiency, The Productive Ward can help organisations to “release time to care”, which can subsequently be used to:
• Focus on other quality initiatives – such as High Impact Actions or focused safety programmes. These initiatives themselves have important quality and cost saving implications. Reducing harm from infections, falls and pressure ulcers will improve patient care and save the NHS money that would be spent on treating these harm events. • Reduce length of stay as patients are discharged appropriately, or harm events are minimised. It is possible to reduce the number of excess bed days and also see a reduction in the occupied bed days. • Take advantage of the efficiency gains to move capacity from acute settings to other service areas, in line with achieving local strategies of moving care closer to home.
Airedale NHS Foundation Trust, for example, has drastically reduced its rates of MRSA and C. difficile infections by using visual management techniques from The Productive Ward programme. It has cut staff sickness levels and improved patient satisfaction. Crucially, the Trust has successfully addressed the problem of medication errors on a ward of elderly patients by improving the handover process and using the time saved to extend the medication round.
Improving infection control
In 2006/07, the Trust was experiencing high infection rates of C. difficile and MRSA. Rates were as high as 128 C. difficile and 12 MRSA bacteraemias. Visual measurement techniques from The Productive Ward Knowing How We Are Doing module were used to bring infection rates down. Tracy Cox, senior sister on Ward 2, a medical ward caring for endocrinology and gastroenterology patients, explains: “We introduced a Knowing How We Are Doing board, which clearly shows how many cases of infection we are having on the ward. It is prominently displayed and highly visible. Staff and patients can see immediately if there is a red square (a case of C. difficile or MRSA) and staff really don’t want there to be any red on the board. The visual management of C. difficile and MRSA has made it real for staff. Before the introduction of the board, they really didn’t know how many cases we were having and, if they did find out via the risk department or Infection Control team, it was just another number. Seeing it in this way has really brought it home to them and made each member of staff take responsibility for preventing infection.” The Trust also proactively promotes the “Clean Your Hands” and “Bare Below the Elbow” campaigns. Staff feel empowered to challenge anyone who fails to wash their hands or use the hand gel, after the campaign was given board-level backing. Tracy said: “Infection rates have come right down. We were seeing three or four cases a week on Ward 2. Since the introduction of the display boards and active infection control measures, we haven’t seen a case for six months. If we do get cases now, they are isolated incidents and the infection rarely spreads.” Airedale NHS Foundation Trust has attributed a year on year cost saving of £177,300 to the avoidance of MRSA and £98,100 to the avoidance of C. difficile. These figures are based on avoided bed day costs (figures reported in Rapid Impact Assessment of The Productive Ward, NHS Institute for Innovation and Improvement, 2011). The trust was also able to save £184,748 through using the visual display boards to report staff absence (Rapid Impact Assessment of The Productive Ward, NHS Institute for Innovation and Improvement, 2011).
Fewer medication errors
Staff on an acute elderly ward at Airedale NHS Foundation Trust, have used The Productive Ward to redesign their handover process to make it more efficient. By cutting handovers down to just 20 minutes, senior sister, Sara Robinson has been able to reinvest staff time on the medication round. She explains further: “We are dealing with elderly patients who can be on up to 14 different types of medication a day, so our medicines round is extremely complex. I wanted to ensure that staff had enough time to do it properly, so we have used the time saved by improving our handover process to make our medicine round longer. It now takes up to two and a half hours but, as a result, the number of errors has come down as the nurses are not rushing. We have also introduced a Medication Incidents Dashboard to record any errors that do occur and to make them visible to staff. When we started this work in August 2009 there were 32 incidents in one month, in February 2011 there were only four.”
Productive Care national QIPP workstream
The Productive Ward is part of the Productive Care national QIPP workstream, led by the NHS Institute. The overall objective of the workstream is to ensure that patients are cared for in the most appropriate “productive” environment – whether that is on a ward, in an operating theatre or in their own homes. “The Productive Ward has the potential to achieve some of the challenging efficiency savings the NHS needs to make over the coming years,” said Lynn Callard, lead for The Productive Care QIPP workstream. “To do this Trusts need to consider how they can reinvest the time released through the programme to help them deliver their strategic objectives. Trusts have shown that it is possible to improve quality while achieving reductions in areas such as harm events, re-admissions rates and excess bed days while at the same time reducing staff absence and improving staff and patient satisfaction.” The workstream aims to have all wards/operating theatres and community trusts operating “productively” by 2013 – as well as contributing around £1.4 bn to the QIPP financial challenge and helping to sustain the NHS, by 2014. A Rapid Impact Assessment of The Productive Ward: Releasing time to care was published in January 2011 by the NHS Institute for Innovation and Improvement, which used a sample of nine Trusts to assess the impact of the programme. The Trusts selected were implementing The Productive Ward in 80% of their wards on average (with a range of 51% to 99%). The report found that the programme delivered an increase of 41.6% in direct patient care time (increasing by 17.7% from baseline of 42.5%). By investing the time in higher quality care the report says that the following benefits can be delivered:
• Better staff satisfaction. • Better patient experience. • Reduced hard events such as MRSA, C. difficile, pressure ulcers and falls. • Reduced same diagnosis readmissions.
The programme has also been proven to offer productivity, efficiency and financial benefits including reduced length of stay (and reduced excess bed day costs per patient); reduced staff sickness and absence; and stock reduction. The case study interviews focussed on identifying impact on the elements of the economic appraisal from a local perspective, such as benefits from stock reduction contributing a direct financial benefit. Data that was available nationally for the Trusts was also analysed to identify evidence of impact from a national data perspective such as opportunity costs from reduced sickness rates contributing an indirect productivity and efficiency benefit. The assessment demonstrated that The Productive Ward has identifiable quality, productivity and efficiency benefits for Trusts. However, the amount of economic benefit banked from the improvements can vary between organisations. For example, as length of stay improves and excess bed days reduce, occupied bed days also decline. This can help implement local strategies such as reducing capacity and shifting care away from the acute setting, or reducing direct cost, or increasing income by delivering more services. Furthermore, the programme has been proven to empower frontline staff to influence and improve the way they work which improves morale and enhances the working lives of nurses and other ward-based staff. As a result, absence rates were shown to decline. With the current challenges and opportunities facing the NHS, The Productive Ward is a programme that Trusts should not overlook. Now, more than ever, Trusts need to embed improvement capability into their everyday work to deliver real and lasting improvements for patients and staff through better efficiency and productivity..
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