Title: Evaluating the ten year impact of the Productive Ward at the clinical microsystem level in English acute trusts
Funder: Department of Health and Social Care

Abstract: This study focuses on a quality improvement intervention specifically designed to improve the efficiency of hospital wards. The Productive Ward (PW) programme seeks to: (1) increase the proportion of time nurses spend in direct patient care, (2) improve experience for staff and patients, and (3) make structural changes to the use of ward spaces to improve efficiency in terms of time, effort and money. Consequently the PW has the potential to meet health needs (by improving the efficiency of care) and is directly concerned with the organisation and delivery of health care. The NHS Institute for Innovation & Improvement (NHSI) developed PW in 2005 and 2006 and first implemented it in England in 2007. It is a self-directed quality improvement (QI) toolkit consisting of three foundational or ‘core’ modules and eight process modules. In subsequent years, the PW has been adopted and implemented internationally. Our study aims to identify and evaluate any sustained impacts and wider legacies of the PW in Trusts in England which have adopted the programme. We will explore how varying times of adoption (‘early’, ‘late’) and differing local approaches to implementation (e.g. whole hospital roll out, pilot wards) have shaped such impacts and/or wider legacies over the previous decade. We will address our aim through two complementary research approaches: • two national surveys of Directors of Nursing in NHS acute Trusts. One survey will focus on ‘early adopters’ (defined as Trusts which had adopted the PW by March 2009 and whom we last surveyed in that year) whilst the second will include both ‘late adopters’ (post-March 2009) and the small number of remaining non-adopters of the PW. Together, the surveys will explore the timing, scale, nature and impact of PW adoption, implementation and assimilation into routine nursing practice in England • organizational case studies in 6 PW-adopting NHS acute Trusts (3 early and 3 late adopters) comprising: - semi-structured interviews and focus groups to explore approaches to implementation, perceived impacts and potential wider legacies of the PW with a range of staff at different organisational levels (including 2 wards that implemented the PW within each Trust) - documentary analyses to (a) further explore local approaches to implementation over time, and (b) inform a critical review and evaluation of the local use of metrics to monitor and report on the impact of the PW (including, for example, any productivity, patient experience and staff wellbeing indicators) - semi-structured interviews with PPI leads and any patients involved with implementation of the PW in order to assess the extent - and how - patient and public engagement has shaped the impact of the PW. There is little evidence relating to the sustainability of the impact of interventions like the PW in clinical microsystems. The proposed study will draw on a unique and detailed dataset compiled in 2009 by the research team enabling the lasting effects (10 years post-adoption by the end of the study) of the PW to be evaluated. We will use the diffusion of innovations framework as an initial model to explore how the PW has been adopted, implemented and assimilated into routine practice. We will generate evidence relating both to any lasting impact of the PW but also as to how different approaches to local implementation shaped the sustained impact(s) of a national QI program in clinical microsystems.

Lay abstract: Clinical microsystems' - and how well they work - are the focus of this call for research proposals. A clinical microsystem can be any health care team providing services to patients, for example, a General Practice, a hospital ward or a clinical unit. This proposal is to find out whether a way of trying to improve how staff in hospital wards work - called the 'Productive Ward' - has been successful in NHS acute hospitals in England and to help managers, doctors and nurses who are continuing to use the approach to make it as useful as possible. The Productive Ward aims to allow nurses on wards to change the way they work so that they are more efficient by reducing waste and stopping nurses from spending time on activities that do not benefit their patients. The Productive Ward was first tried in the NHS in 2007 and in the 8 years that have followed most hospitals in England have used this approach as a way of making some or all of their wards work better. Although the NHS has spent significant amounts of money on using the Productive Ward (over £50 million) still little is known about whether it has worked or not or what its effect has been on patients and carers. Nor do we know whether hospitals that began to use it in 2007 have seen any benefits last. The research team previously studied how the Productive Ward spread through the NHS and have a list of all the 102 hospitals that had began using it by 2009. The researchers now plan to find out whether the wards in those hospitals are working better now than wards that either started to use the Productive Ward at a later date or who have not used the Productive Ward at all. The researchers will survey all 160 NHS acute hospitals in England to update their earlier study and find out whether they are currently, or have previously, used the Productive Ward and, if they have, the way in which they have used it and whether it has worked well. From the results of the survey the researchers will identify 3 hospitals that began to use the Productive Ward first and 3 that started later. The researchers will then carry out research in 2 wards in each of these 6 hospitals. The researchers will interview staff and patients in the hospitals to find out whether using the Productive Ward has brought about any benefits, such as whether nurses spend less time looking for equipment and other unproductive activities that the Productive Ward was supposed to reduce. The researchers will also try to find out whether there have been other benefits of using the Productive Ward, such as developing nurse leaders and whether different ways of introducing the approach have had any impact on the success or otherwise of the Productive Ward. Finding this out will help managers, doctors and nurses and other clinical staff in other hospitals think about how they are using the approach and whether they should do things differently in order to maximise it's impact. The research will take 30 months to finish and will answer whether using the Productive Ward over a 10 year period (2008-17) has made wards in English NHS hospitals more efficient, with less time wasted by nursing staff on activities that do not benefit their patients whilst also improving staff experiences too.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE