The Productive Ward - a programme designed to help nurses and therapists spend more time on patient care - can improve safety, reliability and efficiency on hospital wards, as University Hospitals of Leicester Trust discovered when it implemented a medicines module. Dominick Tompkins explains.
Releasing Time to Care: The Productive Ward was developed by the NHS Institute for Innovation and Improvement as a way of applying the principles of lean thinking to patient care.
The aim of RT2C is to improve the reliability, safety and efficiency of patient care by empowering staff to look at how it is delivered and identify improvements. This often involves, where possible, the elimination of waste that is inherent in all processes and thus releases more time for direct patient care.
The University Hospitals of Leicester is the third largest university trust in England. It has over 100 wards, around 12,000 staff and an annual income of over £500m pounds.
UHL joined the Productive Ward programme in 2009, and currently has 58 wards and departments enrolled. The implementation process is supported by a facilitation team who guide staff through the process and help them to develop improvement techniques and implement sustainable change in the clinical environment.
RT2C has been widely reported on within the nursing literature. However, little has been published relating to the organisational benefits that occur directly as a result of the implementation of the medicines module using RT2C methodology.
Medication safety is high on any NHS organisation’s agenda. The National Patient Safety Agency reports that medication errors can result in people being admitted or readmitted to hospital and if they occur during a hospital stay, can delay discharge (NPSA 2010). They estimate that this could cost the NHS in England more than £750m a year (NPSA 2007).
The medicines module focuses on increasing patient safety by reducing interruptions, errors, and wasted time. From implementing this module in 58 wards and departments we can say it is an intense and challenging module for teams. It encourages staff to step back and examine current practice, unpick unsafe practices, re-design new processes and can often take up to six months to complete. It has however huge benefits for the patient, staff and organisation as the following case study demonstrates.
Ward X is a busy 30-bedded trauma orthopaedic ward. It operates a two team nursing system. Each team is responsible for its own drug administration and rounds. Initial evidence gathered identified the following issues:
- Drug cupboards not consistently locked;
- TTOs left unlocked;
- Lengthy drug rounds;
- Messy and over stocked drug trolleys;
- Delays with discharges.
The drug rounds were timed over a two week period to allow for reliable data to be collected. Findings demonstrated that the morning medication round was taking 189 minutes to complete, with an average of 16 inappropriate interruptions. These identified issues were fed back to ward staff so they understood the need for change and could help shape a new process with facilitator support.
Through using RT2C methodology the staff made the following improvements to the medication process:
- They created a secure storage for medicine delivery from pharmacy;
- They participated in a “5S” (sort, set, shine, standardise, sustain) event of the treatment room and drug trolleysl
- They developed a standard operating procedure (SOP) for the medication rounds, this was agreed by all members of the team which included drugs to be locked away at all timesl
- They implemented red “do not disturb” tabards which applied to all but a few key interruptions identified and agreed by the team.
This has led to a heightened awareness of medication issues and adherence to medication policies within the team.
By undertaking 5S events and examining the storage and management of medication, 55 hours of time per year has been saved which have been re-invested back into patient care. Pre and post timings of the medication round identified a reduction of three minutes per whole morning round equating to an 18-hour saving per year.
Most importantly was the reduction in interruptions of 63 per cent, ensuring more safe, effective and dignified patient care. This is a massive achievement and correlates positively to the National Patient Safety agenda of implementing systems to increase safe drug administration (NPSA, 2007).
This was largely due to the involvement of other MDT members where it was identified that they would frequently interrupt the medication round. The introduction of red tabards is now a visual way of identifying that the nurse is engaged within an important care process. The doctors have also been involved via a medicines champion and a process of continuous communication has been achieved. These illustrate that RT2C is not just a nursing initiative.
Other ward areas throughout the organisation have also seen time savings as a result of redesigning their medicines rounds. A busy surgical assessment unit saved an hour per day across all four drug rounds, and a cardiac ward reduced the time taken to complete their medication rounds by approximately 50 per cent by introducing drug trolleys into their process rather than dispensing from the treatment room. These small savings acquire a significant cumulative result for the organisation as more wards carry out the module.
Sustainability has proved challenging, but this is common in any change process (Buchanan et al 2005). On the case study ward there were issues surrounding the drug trolley, staff would add additional medicines not on the inventory and not store medications in alphabetical order as stated within the SOP. The introduction of daily audits has supported the daily checking of the trolleys and all inappropriate items are removed.
Additional medications were added as a result of continuous staff feedback reflecting that this is a continuous improvement process. A lead consultant is also acting as a medicine champion to help aid sustainability.
Other challenges included staff compliance with the SOP which has been tackled with ongoing monitoring and audit, communication, leadership and facilitation support. Resistance to change is widely documented (Buchanan et al 2005) and through our experience requires the said mechanisms to overcome.
- Improved patient experience and satisfaction due to increased and more focused face to face contact with patients
- Contributing to better informed patients regarding their medication
- Dignity and privacy enhanced as staff able to concentrate solely on that patient and the administration of his/her medication
- Care is safer as risk of medication incident and harm reduced
- Speedier discharge and avoidance of increased stay due to drug errors
- More professional practice through improved adherence to policy and recognition of professional accountability
- A more efficient drug round that is smoother and quicker and staff feel more in control
- Less interruptions meaning reduced risk of error and better reliability of care
- More time to spend face to face with patients and therefore increased job satisfaction
- Improved patient safety and reliability of care
- Improved patient experience
- Staff adhering to policy and are more in control of medication process on the ward, thus happier and less stressed
- Reduced costs – medication stock properly managed, medication rounds shorter
- Contribute to the reduction in medication errors, therefore less time spent by managers managing these situations and potential litigation
- Development of staff to be able to identify problems with processes of care and design, implement and evaluate changes to improve that care
On reflection it is clear that the medicines module has helped ward teams make medication rounds safer, more reliable and efficient throughout the organisation. It has helped the ward staff to reflect on their practice and produce and implement ideas to improve their patient care.
- Buchanan, D., Fitzgerald, L., Ketley, D., Gollop, R., Jones, J. L., Lamont,S. S., Neath, A., Whitby, E., (2005). No going back: A review of the literature on sustaining organizational change, International Journal of Management Reviews, Volume 7, Issue 3, pages 189–205.
- National Patient Safety Agency, (2007). Safety in doses: Medication safety incidents in the NHS. The fourth report from the Patient Safety Observatory (PSO/4). London: NPSA.
- National Patient Safety Agency, (2010). Reducing medication errors,http://www.npc.nhs.uk/improving_safety/improving_safety/resources/Medication_Error/Reducing_5mg.pdf, accessed 13.06.20011.
- NHS Institute for Innovation and Improvement, (2007). Releasing Time to Care. Coventry: NHS Institute for Innovation and Improvement.
Acknowledgements to: releasing time to care facilitators Geoff Davison, Kerry O’Reilly and Jenny Kay, head of nursing Maria McAuley and PhD student Lucy Sitton-Kent.