Inpatient care swallows funds and staff time. Jennifer Taylor reports on a pilot scheme that aims to break the cycle

Productivity is crucial to the NHS and ways to increase it are being tested across the service. One of the key areas over the next 18 months will be acute wards, in particular the productive ward programme being developed by the NHS Institute for Innovation and Improvement.

The aim is to increase the amount of time nurses spend with patients and, as a result, improve their experience and outcomes, increasing safety, improving flow and reducing length of stay. The hypothesis is that as the amount of time spent on direct care goes up, costs will reduce.

So why is the institute focusing on wards? 'It is the place where safe and reliable care can happen or not,' says NHS Institute head of service improvement Kate Jones.

The vast majority of NHS staff are employed as nurses or allied health professionals in an acute setting. Around£25bn a year is spent on acute health services, which equates to 41 per cent of the NHS budget. Of that, 68 per cent (around£17bn) is spent on acute bed users.

At the moment, ward standards and performance are maintained by hard work and vigilance, according to the institute.

Although wards are under constant pressure to increase performance, measurement is not relevant to ward-level decision-making and is not systemised.

As a result, staff morale and direct care time are low, and there is little slack in the system to allow for improvement. Ward staff are torn between patient and productivity priorities, and patients see a disorganised and frantic environment.

There is also a perception that working flat out is doing a job well.

The institute envisages a future where the ward environment is calm and predictable, and ward staff have the knowledge and environment to develop systems that reliably provide timely, safe and appropriate care.

Realising this future, it says, will result in increases in direct care time, staff morale and safety. Length of stay should decrease, with a corresponding cost saving. Employees will be more engaged and absenteeism should fall.

Patient malnutrition

Increasing direct care should also cut down levels of patient malnutrition. And there should be longer periods between events of hospital-acquired infections, and between near-misses and accidents.

The proposed future looks bright, but how can it be delivered?

Nurses spend a huge proportion of their time on the ward 'hunting and gathering' for equipment, says Ms Jones, so improved systems are part of the solution. Lean principles for improving flow and eliminating waste will play their part. She says waste is about time and effort, not just money. Wound infection, for example, could be seen as a source of waste because it requires additional nursing time and medication.

Four trusts will pilot the Productive Ward principles: Barnsley Hospital foundation, Luton and Dunstable Hospital foundation, North Hampshire Hospitals and Royal Liverpool and Broadgreen University Hospitals.

'We'll be looking at how patients flow through the ward,' says Ms Jones. This will include identifying factors that slow down patients' progress and whether processes are being carried out that do not add value, such as patients being asked for a case history several times.

Other factors include: effective feeding and observation; assessments for patients at risk of falling; hand hygiene; and whether nurses are able carry out medication rounds without interruption.

One of the aims is to develop teamwork and a culture where it is everyone's job to deliver quality care. 'It can be like trying to rebuild a plane while it's flying,' says Ms Jones.

Work at the pilot sites will lead to the development of a programme launch next April, with advice for trusts on changes needed to drive productivity in their own wards.

Ms Jones predicts that one of the changes will be around generic development needs for ward sisters. Are they clear about standards? Are they good at teamwork, briefing people and inspiring staff to try something new? 'It's about good leadership,' says Ms Jones.

Sisters will also need to be sensitive to the impact of their ward on the bigger system.

At the moment, many wards do not have information on issues like length of stay and hand hygiene, so it is difficult to measure improvement.

The pilots will show whether changes are applicable across the board or if they need to be different for surgical and medical wards.

'Chief executives need to be aware of these approaches and techniques,' says Ms Jones. 'They can then generate the right culture for this to be implemented.'

At each level, she says, leaders need to create an environment where it is OK to test new things; even if there are failures along the way, lessons can be learned.

And there should be ward-level experts such as sisters, she adds, who can run and measure improvement cycles, then coach staff nurses to carry on the good work.

* HSJ will be teaming up with sister publications Nursing Times and Therapy Weekly to support the NHS Institute's productive ward programme over the next 18 months.

Applying lean principles to orthopaedics

The orthopaedics ward at Luton and Dunstable Hospital foundation trust is one of the pilots for the NHS Institute's productive ward programme.

Chief executive Stephen Ramsden says: 'Orthopaedics is under severe pressure, with demand exceeding capacity. We need to decrease demand and make the service as efficient as possible.'

Mr Ramsden hopes the system for getting patients to theatre, which relies heavily on ward nurses, is one area that will improve.

'If both theatre and ward could be part of the same lean principles, we would expect to see less waste in the operating theatre.'

He adds: 'We want to free nurses from doing non-value added work.'

Increasing hands-on nursing care would result in decreased length of stay on wards, a safer environment for patients and better patient and staff satisfaction, he says.