Reported implementation lessons from a national quality improvement initiative; Productive Ward: Releasing Time to Care™. A qualitative, ward-based team perspective

A Hospitality Improvement Intervention in Residential Care Does Not Warrant Staff Job Satisfaction or Turnover Intention: A Cross-Sectional Survey Study Investigating the Hostmanship Program

Background

Accountability pressure is rising in healthcare, and this demonstrates that the quality of care provided within a residential care setting is of utmost importance. Hostmanship is a quality improvement program focusing on person-centered care in residential care settings.

Objectives

This study aimed to explore the influencing factors for job satisfaction and intention to leave among healthcare workers and the difference in job satisfaction and intention to leave the employer between residential care centers with and without Hostmanship.

Methods

A quantitative, cross-sectional study was conducted in sixteen Flemish residential care settings in Belgium. A total of 293 participants completed the questionnaire, divided into two groups: the group with Hostmanship (n = 139), at least one year into a change process implementing Hostmanship, and the group without the Hostmanship program (n = 154). Hierarchical logistic regression analysis estimated effects between demographic characteristics (block one), facility management, staffing and Hostmanship (block two), work characteristics (block three), and work engagement or burnout dimensions (block four) as explanatory variables of job satisfaction and turnover intention as outcome variables.

Results

This study confirmed the positive impact of social capital and decision latitude on staff member job satisfaction, as shown in previous findings. Age and workload were associated with turnover intentions. A hierarchical logistic regression model explained 68.7 % of the variance in workers' job satisfaction, and a hierarchical logistic regression explained 49.2% of the variance in their intent to leave. Also, no effects were found for Hostmanship on staff job satisfaction and intention to leave.

Conclusions

This study shows how a quality improvement project such as Hostmanship could produce counterintuitive results for organizations in elderly residential centers. However, results inconsistent with literature were found. It is unclear whether Hostmanship warrants job satisfaction or retaining personnel. Future research must take into consideration success factors when implementing new quality initiatives. A general framework for successful implementation in the healthcare sector should be provided.

Exploring the emotional experience of lean

PURPOSE

This research aims to contribute to the literature on Lean implementation in healthcare by studying the emotional experiences of the relevant actors related to a Rapid Process Improvement Workshop (RPIW) in a UK healthcare context. The purpose of this study was to go beyond what people think about Lean and towards an exploration of their subjective, emotional and "feeling" experience and whether that emotional experience influenced Lean implementation.

DESIGN/METHODOLOGY/APPROACH

A phenomenological and symbolic interactionist qualitative case study was undertaken. Data related to participants' emotional experience were collected through non-participant observation and semi-structured interviews. Data were analysed using thematic network analysis.

FINDINGS

This paper provides novel insights into the emotional experience of Lean as experienced through an RPIW. The findings reveal that participation in an RPIW is much more than a technical process. It influences how people feel about themselves, is based on relationships with others, and requires mental, physical and emotional effort. All of these factors influence engagement with, initiation of and sustainability of the RPIW.

RESEARCH LIMITATIONS/IMPLICATIONS

A new conceptual framework for the planning and implementation of RPIWs has been developed. However, because of the chosen research approach, the results may lack generalisability. Therefore, researchers are encouraged to test the framework and proposed practice implications.

ORIGINALITY/VALUE

Despite emotions being an integral part of individual and social everyday life, emotional experience has not been studied in relation to Lean. This study is the first to explore emotions in relation to Lean, with implications for practice as to how RPIWs are managed with a new framework for implementation being proposed.

Optimizing nursing time in a day care unit: Quality improvement using Lean Six Sigma methodology

OBJECTIVE

This study applies Lean Six Sigma (LSS) to improve the efficiency of a private hospital day care unit and generate a positive impact on optimizing nursing time and improving personalized patient care and staff satisfaction.

DESIGN

A prospective interventional study using pre- and post-evaluation.

SETTING

A day care unit at a private hospital.

PARTICIPANTS

Nurses and patients from the day unit.

INTERVENTION(S)

Define, Measure, Analyze, Improve and Control was used as an overarching problem-solving framework. All front line staff, clinical leaders and managers were supported as active change agents in the quality improvement (QI) initiative. Multiple interventions were adopted across the service that aimed to de-implement non-value added activities and enhance processes with activities that added value.

MAIN OUTCOME MEASURES

Patient turnaround times (PTTs), nursing time, nurse-patient ratio, nurse and patient survey.

RESULTS

A post-implementation evaluation highlighted significant improvements in service performance and patient and staff satisfaction. Significant added value includes a reduction in PTTs, an increase in nursing care time and improvement in the nurse-patient ratio.

CONCLUSION

This project identified that utilizing LSS that relies on collaborative team effort is effective in creating a positive organizational culture for improvement and change. The Six Sigma tools and techniques provide evidence-based approaches that support QI in practice.

Evaluation of the impact of an augmented model of The Productive Ward: Releasing Time to Care on staff and patient outcomes: a naturalistic stepped-wedge trial

Background

Improving the quality and efficiency of healthcare is an international priority. A range of complex ward based quality initiatives have been developed over recent years, perhaps the most influential programme has been Productive Ward: Releasing Time to Care. The programme aims to improve work processes and team efficiency with the aim of ‘releasing time’, which would be used to increase time with patients ultimately improving patient care, although this does not form a specific part of the programme. This study aimed to address this and evaluate the impact using recent methodological advances in complex intervention evaluation design.

Method

The objective of this study was to assess the impact of an augmented version of The Productive Ward: Releasing Time to Care on staff and patient outcomes. The design was a naturalistic stepped-wedge trial. The setting included fifteen wards in two acute hospitals in a Scottish health board region. The intervention was the Productive Ward: Releasing Time to Care augmented with practice development transformational change methods that focused on staff caring behaviours, teamwork and patient feedback. The primary outcomes included nurses’ shared philosophy of care, nurse emotional exhaustion, and patient experience of nurse communication. Secondary outcomes covered additional key dimensions of staff and patient experience and outcomes and frequency of emergency admissions for same diagnosis within 6 months of discharge.

Results

We recruited 691 patients, 177 nurses and 14 senior charge nurses. We found statistically significant improvements in two of the study’s three primary outcomes: patients’ experiences of nurse communication (Effect size=0.15, 95% CI; 0.05 to 0.24), and nurses’ shared philosophy of care (Effect size =0.42, 95% CI; 0.14 to 0.70). There were also significant improvements in secondary outcomes: patients’ overall rating of ward quality; nurses’ positive affect; and items relating to nursing team climate. We found no change in frequency of emergency admissions within six months of discharge.

Conclusions

We found evidence that the augmented version of The Productive Ward: Releasing Time to Care Intervention was successful in improving a number of dimensions of nurse experience and ward culture, in addition to improved patient experience and evaluations of the quality of care received. Despite these positive summary findings across all wards, intervention implementation appeared to vary between wards. By addressing the contextual factors, which may influence these variations, and tailoring some elements of the intervention, it is likely that greater improvements could be achieved.

Trial registration number

UKCRN 14195.

The 10-year impact of a ward-level quality improvement intervention in acute hospitals: a multiple methods study

Background

The ‘Productive Ward: Releasing Time to Care’™ programme (Productive Ward; PW) was introduced in English NHS acute hospitals in 2007 to give ward staff the tools, skills and time needed to implement local improvements to (1) increase the time nurses spend on direct patient care, (2) improve the safety and reliability of care, (3) improve staff and patient experience and (4) make structural changes on wards to improve efficiency. Evidence of whether or not these goals were met and sustained is very limited.

Objective

To explore if PW had a sustained impact over the past decade.

Design

Multiple methods, comprising two online national surveys, six acute trust case studies (including a secondary analysis of local audit data) and telephone interviews.

Data sources

Surveys of 56 directors of nursing and 35 current PW leads; 88 staff and patient and public involvement representative interviews; 10 ward manager questionnaires; structured observations of 12 randomly selected wards and documentary analysis in case studies; and 14 telephone interviews with former PW leads.

Results

Trusts typically adopted PW in 2008–9 on their wards using a phased implementation approach. The average length of PW use was 3 years (range < 1 to 7 years). Financial and management support for PW has disappeared in the majority of trusts. The most commonly cited reason for PW’s cessation was a change in quality improvement (QI) approach. Nonetheless, PW has influenced wider QI strategies in around half of the trusts. Around one-third of trusts had impact data relating specifically to PW; the same proportion did not. Early adopters of PW had access to more resources for supporting implementation. Some elements of local implementation strategies were common. However, there were variations that had consequences for the assimilation of PW into routine practice and, subsequently, for the legacies and sustainability of the programme. In all case study sites, material legacies (e.g. display of metrics data; storage systems) remained, as did some processes (e.g. protected mealtimes). Only one case study site had sufficiently robust data collection systems to allow an objective assessment of PW’s impact; in that site, care processes had improved initially (in terms of patient observations and direct care time). Experience of leading PW had benefited the careers of the majority of interviewees. Starting with little or no QI experience, many went on to work on other initiatives within their trusts, or to work in QI at regional or national level within the NHS or in the private sector.

Limitations

The research draws on participant recall over a lengthy period characterised by evolving QI approaches and system-level change.

Conclusions

Little robust evidence remains of PW leading to a sustained increase in the time nurses spend on direct patient care or improvements in the experiences of staff and/or patients. PW has had a lasting impact on some ward practices. As an ongoing QI approach continually used to make ongoing improvements, PW has not been sustained, but it has informed current organisational QI practices and strategies in many trusts. The design and delivery of future large-scale QI programmes could usefully draw on the lessons learnt from this study of the PW in England over the period 2008–18.

Funding

This National Institute for Health Research Health Services and Delivery Research programme.

Nurses' Perspectives on Lean Redesigns to Patient Flow and Inpatient Discharge Process Efficiency

As hospitals around the world increasingly face pressure to improve efficiency, "Lean" process improvement has become a popular approach to improving patient flow. In this article, we examine nurses' perspectives on the implementation of Lean redesigns to the inpatient discharge process. We found that nurses experienced competing demands and tensions related to their time and professional roles and responsibilities as a result of Lean. Four main themes included (a) addressing the needs of individual patients, while still maintaining overall patient flow; (b) meeting discharge efficiency targets while also achieving high patient satisfaction scores; (c) "wasting time" to save time; and (d) the "real" work of providing clinical care versus the "Lean" work of process improvement. Our findings highlight the importance of soliciting hospital nurses' perspectives when implementing Lean process improvements to improve efficiency and patient flow.