Central Manchester NHS to Reduce Staff Absenteeism

They have succeeded on individual wards, but are trusts in Nottingham and Manchester up to the bigger challenge of transforming whole hospitals, asks Stuart Shepherd

In September 2007, following the unprecedented success of the individual Productive Ward field test sites, two NHS trusts embarked on a strategy to implement the Productive Ward across their entire hospital systems. The trusts were invited to do this by the NHS Institute because both had an excellent track record in hospital-wide improvement initiatives.

Nottingham University Hospitals trust and Central Manchester and Manchester Children’s University Hospitals trust were enthusiastic about the programme. They were confident of the potential of Productive Ward to increase the nursing time available for direct patient care dramatically.

Nonetheless, as “whole hospital” testing grounds, a vanguard for acute and other services far and wide, they knew they were stepping somewhat into the unknown and fully acknowledged the challenge ahead.

A year in, their learning is already proving to be invaluable and informing important further developments in the national roll-out of the Productive Ward and how its impact will be measured. Their progress has also contributed significantly to the continuing growth of the Productive series.

The Nottingham story

Having familiarised itself with the tools and principles of Productive Ward on two pilot wards, Nottingham began whole hospital roll-out in November 2007. Eight new teams from NHS England’s fourth largest trust join the programme approximately every 10 weeks, and to date Productive Ward is being implemented in 34 wards as well in as the emergency department.

“Two years from the start of roll-out [November 2009], our aim is to have Productive Ward on 74 from a total of more than 90 wards,” explains Kerry Bloodworth, assistant director of nursing and Productive Ward project lead. “The most advanced wards have completed all the foundation modules and are moving on to their fifth process module. Their Productive Ward ‘house’ is almost complete.”

She adds: “We have a team of four senior project nurses – all former ward sisters with good communication and influencing skills but little or nothing in the way of a background in improvement skills – to meet the demands those aspirations place on us.”

Trust chief executive Peter Homa chairs the project’s monthly steering group, which is also attended by directors from estates and informatics alongside representatives from the different ward cohorts in the implementation phase.

“The fact that he has not missed a single meeting is a clear indication of the commitment our chief executive gives to Productive Ward,” says Ms Bloodworth. “It also means there is somebody there who can very quickly unblock any issues or resource needs that might otherwise get in the way.”

Publicly displayed performance measurement boards on the wards running Productive Ward show the improvements to which the programme is contributing. These go up during the Knowing How We Are Doing foundation module and indicators on them include patient and staff satisfaction, healthcare-acquired infection rates, falls, pressure areas, length of stay and staff sickness. Where adverse or negative measures are recorded, the same boards also show which actions staff are taking to reduce or eliminate them.

Patients and visitors are responding positively to the data, Ms Bloodworth notes: “All our inpatients are given the opportunity to fill out a modified PICA survey which assesses their levels of satisfaction. This provides instant feedback to the staff teams about what patients think of their experience on the ward. The response varies across wards but overall the satisfaction rating is above 80 per cent.”

As with many other trusts, there has been a huge drive at Nottingham – with good effect – to reduce healthcare-acquired infections. MRSA rates, for instance, are down by 68 per cent and C difficile by 54 per cent. While other contributing initiatives such as clean hands and deep clean need to be considered, a part of those outcomes, it seems fair to say, may be attributable to Productive Ward.

“If you speak to a Productive Ward ward sister, what she will tell you is that up until having performance data, she would know where she could find the MRSA infection rate for her ward,” says Ms Bloodworth. “Now with infection control data in public view, it is much more of a live issue for her and the clinical team and it reassures patients and families, who can see what is being done to tackle it and how it is coming down.”

Anecdotal evidence arising from the trust’s experience of implementing the Well Organised Ward module suggests savings of between £5,000 and £10,000 can be made by returning excess stock to stores.

One unequivocal measure at Nottingham that has improved with Productive Ward is direct care time. “Across the trust, the proportion of the total working time available to nurses to spend with patients has gone up from 38 per cent to 52 per cent,” reports Ms Bloodworth. “Data is now driving performance on the wards. “When it starts to influence things like patient flow in the emergency department, the impact of Productive Ward leads us further to where we need to be, to what our chief executive describes as the Productive Hospital.”

The Manchester story

“For us, Productive Ward came just at the right time. We have been able to use it as a single vehicle for delivering three distinct service development initiatives,” says Gill Heaton, director of patient services and chief nurse at Central Manchester. “Now all our aspirations for the patient experience, patient safety, and productivity and efficiency can be pulled together in this one programme.”

There are 82 wards or departments where Central Manchester wants to use Productive Ward (including some outpatient areas, children’s high dependency and the adolescent mental health unit) and bring the skill sets into the clinical team.

“We plan to complete by 2010, using a 12-week roll-out that brings in between six and eight new areas at a time,” says Dawn Pike, assistant director of nursing. “One of the challenges we face at the moment is that our hospitals are across three sites, so we have phased the introduction of Productive Ward to children’s services for after their relocation in 2009. “We believe that we can bring service improvement to all of these areas.”

The evidence suggests she is right. Every quarter the trust has been using an “activity follow” process to measure the time available to registered nurses to give to direct patient care. Across all wards that figure has gone up by 8 per cent.

“That might not sound a lot,” says Ms Pike, “but actually it equates to 57 extra minutes across a 12-hour shift and it is in this more meaningful form that we relay it to the nursing teams.”

Those figures and others from a range of 12 quality indicators arrive as “performance dashboard data” on the Productive Ward wards each month in a visually striking bar graph format. Just as at Nottingham, the data is on public display and along with it are the actions the ward team are taking to make the necessary improvements.

“The data tells the team how they are doing and where the issues lie, as well as informing the improvement process. If the number of falls is going up, for instance, they might use process mapping and some of the other tools and techniques they have learned to better understand what’s happening and what to do about it. We know it’s an approach that works. Before the Productive Ward programme started, one of our first-phase wards used to average 12 falls a month. Now that is down to between three and four a month,” says Ms Pike.

Evidence shows that Productive Wards at Central Manchester have improved how they identify nutritional risk among vulnerable patients. The trust is collating information from its first-phase wards that should also demonstrate a quantifiable reduction in food waste. An early briefing to the catering team about the implementation of the programme, and their subsequent involvement in the process-mapping of meal delivery from kitchen to patient, has helped to develop partnership working beyond the confines of the clinical area.

“It might be because we are still early in the journey, but it is hard to articulate, to capture the impact that Productive Ward might have in other departments, out across our trust and in the wider health economy,” says Ms Pike. “We are talking with the Institute about how we progress our evaluation of the data across the whole hospital, about what measures we can put in place to be clearer about what, in terms of impact, Productive Ward is responsible for.”

FOR GOOD MEASURE

The NHS Institute is working to support trusts such as Nottingham and Central Manchester to further understand how the data they are collecting from the wards can be interpreted at an organisational level.

“First, we have embarked on a major national study of the spend and impact of the Productive Ward across the whole NHS with a leading academic partner,” says Maggie Morgan-Cooke, NHS Institute lead on the Productive Ward and Productive Community Hospital.

“We are also developing a tool to help organisations benchmark the impact of Productive Ward across a dozen or so key indicators being used at the whole hospital sites and elsewhere.

“This will help trusts to quantify more accurately the difference that Productive Ward makes, not just to time released back into direct patient care, but to safety issues including reductions in falls and medicine errors, to length of stay, time taken in admission and discharge procedures and staff absenteeism.”

Activities to measure and benchmark the impact of the Productive Ward are also underway at a regional level, led by NHS South East coast. The NHS Institute will build the learning from this into its current benchmarking tool development.

“There is a lot of interest in this area and we hope to be able to formally launch the benchmarking tool in December,” says Ms Morgan-Cooke.

“It will allow NHS organisations to understand how well individual wards are currently doing, compare between wards in the hospital and compare with other hospitals.

“At the end of the day, though, this is about measuring for improvement, not measuring for judgement or performance.

“It is about giving NHS organisations the tools to continuously strive to provide better experiences and services for patients.”

Richard Reid is the founder of Pinnacle Proactive, Specialising in theEmployee Assistance ProgramStress ManagementStaff Retention & Absenteeism. Take a Proactive Approach to Growing Your Organisation & its People. For more info visit http://www.pinnacleproactive.com

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