Corell Uiversity ILR School DigitalCommos@ILR Iteratioal Publicatios Key Workplace Documets 2013 Work Orgaisatio ad Iovatio - Case Study: Nottigham Uiversity Hospitals NHS Trust, UK Beth Foley Istitute of Employmet Studies Aette Cox Istitute of Employmet Studies Follow this ad additioal works at: http://digitalcommos.ilr.corell.edu/itl Thak you for dowloadig a article from DigitalCommos@ILR. Support this valuable resource today! This Article is brought to you for free ad ope access by the Key Workplace Documets at DigitalCommos@ILR. It has bee accepted for iclusio i Iteratioal Publicatios by a authorized admiistrator of DigitalCommos@ILR. For more iformatio, please cotact hlmdigital@corell.edu.
Work Orgaisatio ad Iovatio - Case Study: Nottigham Uiversity Hospitals NHS Trust, UK Abstract [Excerpt] Nottigham City Hospital is part of Nottigham Uiversity Hospitals NHS Trust (NUH). NUH was formed i 2006 after the City Hospital uderwet a merger with Quee s Medical Cetre. Quee s Medical Cetre ow forms the emergecy care site ad the City Hospital houses services for strokes, heart disease ad cacer, focusig o plaed care ad those with log-term coditios. NUH is ow oe of the largest ad busiest acute Trusts i Eglad, employig 13,000 staff. It provides services to over 2.5 millio residets of Nottigham ad its surroudig commuities, ad specialist services to a further 3 4 millio people from eighbourig couties each year. The Trust has a aual icome of GBP722.5 millio (approximately 858 millio as at 20 Jauary 2013), 90 wards ad aroud 1,700 beds. The Trust prides itself o stadig at the forefrot of may research programmes ad ew surgical procedures; it is the oly NHS trust i the coutry to have had three successful bids for Biomedical Research Uits. As a teachig trust, NUH has a strog relatioship with the Uiversity of Nottigham ad other uiversities across the East Midlads, ad plays a importat role i the educatio ad traiig of doctors, urses ad other healthcare professioals. Keywords work orgaizatio, iovatio, Nottigham Uiversity Hospitals NHS Trust Commets Suggested Citatio Foley, B. & Cox, A. (2013). Work orgaisatio ad iovatio - Case study: Nottigham Uiversity Hospitals NHS Trust, UK. Dubli: Europea Foudatio for the Improvemet of Livig ad Workig Coditios. This article is available at DigitalCommos@ILR: http://digitalcommos.ilr.corell.edu/itl/248
Work orgaisatio ad iovatio Case study: Nottigham Uiversity Hospitals NHS Trust, UK Click for cotets Wyattville Road, Loughlistow, Dubli 18, Irelad. - Tel: (+353 1) 204 31 00 - Fax: 282 42 09 / 282 64 56 email: iformatio@eurofoud.europa.eu - website: www.eurofoud.europa.eu
Cotets Itroductio Backgroud to the orgaisatio Nature of the iovatio Process of implemetig the iovatio Reactios ad challeges Impact o employees Impact o the orgaisatio Lessos leart ad future plas Refereces 1 2 3 5 7 9 11 13 14
Itroductio The public health sector was decided o as a case study because of the pressures o the sector i recet times, its importace as a major employer ad evidece that work orgaisatio iovatio ca be drive by a bottom-up employee process. There is o doubt that health is a sigificat sector; a report from the Europea Observatory o health systems ad policies estimated that expediture o health across the EU Member States i 2010 accouted for 9.0% of GDP (OECD, 2012). Approximately 10% of the active EU workforce is egaged i the health sector i its widest sese, icludig physicias, urses, pharmacists, admiistrative ad supportive staff, researchers, teachers ad traiees. The OECD report discussed the potetial effect of risig govermet debt ad deficits o social expediture, coupled with health systems facig major ew challeges such as ageig populatios, ew health threats, rapid developmet of ew techologies, risig expectatios of citizes, ad their implicatios for spedig o healthcare. The coclusio is that a efficiet ad effective health workforce is ecessary to respod adequately to these challeges. Moreover, the healthcare sector is oe which is exposed to relatively high levels of techological iovatios, thus exposig the workforce to chage i the ature of products ad services. Because it faces ogoig pressures o efficiet service delivery due to rapidly expadig demad as a result of a ageig populatio, coupled with fiscal pressures o levels of public fiacig for healthcare, the healthcare sector could beefit from itroducig High Performace Work Practices. Furthermore, a recet EU cosultatio documet Gree paper o the Europea Workforce for Health (2008) ad a Policy Dialogue i 2010 cocluded that improvig work orgaisatios ad coditios were importat factors i recruitig ad retaiig a high quality workforce. The UK has bee particularly active i creatig the coditios for ew work methods ad processes. The key Departmet of Health strategy documets drivig iovatio i health iclude: High quality care for all, 2008 Iovatio for a healthier future, 2009 The Health White Paper: Equity ad excellece Liberatig the NHS, published i July 2010. I particular, the UK Departmet of Health established the NHS Istitute for Iovatio ad Improvemet to provide support ad ispiratio to idividual healthcare orgaisatios. The NHS Istitute has udertake a umber of projects ad developed various support mechaisms to eable orgaisatios to udertake social iovatios based o work orgaisatio, as opposed to cliical iovatios i drug treatmets or therapies which ted to receive greater attetio withi healthcare commuities. 1
Backgroud to the orgaisatio Nottigham City Hospital is part of Nottigham Uiversity Hospitals NHS Trust (NUH). NUH was formed i 2006 after the City Hospital uderwet a merger with Quee s Medical Cetre. Quee s Medical Cetre ow forms the emergecy care site ad the City Hospital houses services for strokes, heart disease ad cacer, focusig o plaed care ad those with log-term coditios. NUH is ow oe of the largest ad busiest acute Trusts i Eglad, employig 13,000 staff. It provides services to over 2.5 millio residets of Nottigham ad its surroudig commuities, ad specialist services to a further 3 4 millio people from eighbourig couties each year. The Trust has a aual icome of GBP722.5 millio (approximately 858 millio as at 20 Jauary 2013), 90 wards ad aroud 1,700 beds. The Trust prides itself o stadig at the forefrot of may research programmes ad ew surgical procedures; it is the oly NHS trust i the coutry to have had three successful bids for Biomedical Research Uits. As a teachig trust, NUH has a strog relatioship with the Uiversity of Nottigham ad other uiversities across the East Midlads, ad plays a importat role i the educatio ad traiig of doctors, urses ad other healthcare professioals. O its establishmet i 2006, however, NUH was cofroted with a umber of challeges. At the time, the Trust was ruig a GBP20 millio deficit. More recet cuts to public spedig mea that the eed to make savigs remais a importat strategic priority for the orgaisatio; the Trust is seekig to save GBP40 millio i 2011/12 aloe. The merger of two large hospitals also preseted the challege of stadardisig policies, procedures ad workig practices across the two sites, which cotiues to be a maagemet priority. The Trust has embarked o a umber of iitiatives over the past few years, which have bee desiged to address these issues. I 2007, it became oe of the first whole site pilots of the Productive Ward programme. Sice the, its ambitios have broadeed, ad the curret visio is to be Eglad s best acute teachig trust by 2016. This will ivolve esurig the Trust is rated as the best or amog the best i the followig areas: cliical outcomes, patiet experiece, staff satisfactio, teachig ad traiig, research ad providig services which are value for moey. This ambitious objective has partly ispired Better for You a programme which ecompasses all areas of the Trust ad aims to act o the ideas of staff ad patiets to improve systems ad processes ad focus o delivery of high-quality, efficiet patiet care. This programme was also partly ispired by the Productive Ward programme. As part of this case study, iterviews were carried out with the Assistat Director of Nursig, who is leadig o the Productive Ward programme, two ward maagers o participatig wards, ad employees workig withi the programme i frot lie roles as urses ad healthcare assistats. 2
Nature of the iovatio The Productive Ward (PW) programme was desiged by the NHS Istitute for Iovatio ad Improvemet, i partership with urse leaders ad idustry parters, i 2005. The programme was iteded to icrease the efficiecy of NHS workig practices, therefore creatig more time for staff to devote to patiet care. I more recet years, however, it has also bee desigated a importat tool i helpig the NHS cofrot the biggest challege of its history as recet cuts to public spedig mea it must make GBP15 20 billio worth of efficiecy savigs by 2014. The PW programme purpose states that it aims to provide tools specifically developed to egage frotlie staff i the iitiatio ad implemetatio of chage, givig them the iformatio, skills ad time they eed to idetify areas for improvemets. The programme draws o priciples of lea thikig, which aims to focus o the values which drive healthcare ad work to maximise operatioal processes which achieve those values, while reducig activities which do ot. It is iteded that additioal time ca be released through more efficiet operatioal routies, better orgaised ward eviromets ad effective use of patiet data. This should lead to improvemets i health ad safety, the quality ad reliability of patiet care ad the patiet experiece. The programme was piloted at four test sites i 2006. The NHS Istitute ad a cosultacy firm with expertise i lea maagemet processes spet a year i these pilot locatios lookig at how wards operated, ad developig ad refiig the tools ad modules to improve efficiecy. I 2007, the project was tested o a larger scale ad NUH became oe of the first whole hospital test sites. The hospital voluteered for this role; the project lead believed this was liked to the challeges they faced, relatig to both the recet merger ad the eed to reduce a substatial fiacial deficit. The PW programme ecompasses three foudatio modules ad ie process modules. The module activities ad resources iclude traiig (described below), supplemeted by toolkits for use at ward level. The foudatio modules are: Kowig How We Are Doig (KHWAD): this ivolves measuremet of curret performace ad usig the data to moitor the impacts of chage ad to improve the safety ad quality of patiet care. Participatig wards have itroduced data boards, which visually display recet data o key performace areas such as ifectio rates, falls ad pressure ulcers. The data preseted is desiged to tie ito all of the hospital s improvemet iitiatives, icludig Essece of Care ad Nursig Metrics. Well Orgaised Ward: this module aims to simplify the workplace ad reduce waste by esurig all equipmet ordered is ecessary, ad i the right place at the right time. Patiet Status at a Glace: this liks to the trust-wide iitiative to reduce iteral waits. These are accompaied by ie process modules i areas such as meals, medicies, patiet observatios ad patiet hygiee. Teams of three or four relevat staff are assiged to implemet each of these modules. These staff may voluteer for the role due to their particular iterest i a area or the ward maagers may select staff they feel would beefit from the additioal resposibility this is at the discretio of the ward maager. The modules are ru as three traiig days provided by the PW project team spread out over a two- or three-moth period, which all staff implemetig a module must atted, with morigs spet i a classroom settig ad afteroos set aside for directed study time. The lead reported that certai modules are more popular particularly those which were also part of the Care Quality Commissio s ispectio stadards, such as meals, medicies ad observatios. Less popular modules iclude the ward roud ad patiet hygiee ad the lead suggested this may be because they are viewed as bread ad butter activities. However, each ward has to complete all modules. 3
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK NUH embarked o the PW programme oe year after the merger of the two large hospitals. The project lead believed Trust maagemet viewed the iitiative ot oly as a tool to help the two hospitals stadardise their workig practices, but also to help the orgaisatio fiacially, give that it was attemptig to deal with a GBP20 millio deficit. The lead stated that the Trust s executive team was cofroted with two choices. O the oe had, they could have adopted the slash ad bur approach, i which the orgaisatio simply cut jobs ad services. Although this would have bee a fairly easy way to brig costs dow, the lead poited out that it was viewed as udesirable, sice it was ot cosidered a sustaiable policy ad it would be difficult to esure cuts were made i the right areas. Istead, the Trust was kee to esure that savigs were achieved through a more trasformatioal process, with a focus o quality ad efficiecy. It was hoped that PW could cotribute to fidig efficiecies i a way that cotiued to esure high-quality care for patiets ad a positive experiece for staff. The Lead cited the three cetral motivatios behid the programme as safety, quality ad the improvemet of the patiet ad staff experiece. The Lead felt that much of the cotet of the PW programme was actually focused o ursig practices; it was more about becomig a productive urse. She felt this focus was a importat oe, sice urses are traditioally uder great time pressure. It is therefore rare for them to have a opportuity to cosider the way they work ad where they could make improvemets. The PW programme is ot the oly improvemet iitiative that the hospital is curretly udergoig. For example, sice 2001, the hospital has bee implemetig the Essece of Care guidelies draw up by the Departmet of Health. This programme ecourages hospitals to bechmark their performace i 12 key areas desiged to capture the fudametals of patiet care. Nurses are also moitored accordig to Nursig Quality Metrics, which moitor the weekly results of ursig audits ad the Patiet Experiece Questioaire. The project team has attempted to esure that the focal areas ad data collected i relatio to the PW programme tie i, wherever possible, with the priorities of these additioal iitiatives. 4
Process of implemetig the iovatio The PW programme is implemeted by a desigated project team. This is led by the Assistat Director of Nursig, who has bee i the role sice 2004 ad leadig the programme sice the Trust s first egagemet with PW i 2007. The team was iitially made up of four former ward maagers; this has ow bee reduced to two as the programme becomes embedded. The team was selected o the basis of commuicatio ad leadership ability, rather tha their existig kowledge of service improvemet; the project lead poited out that service improvemet methods are more easily taught tha commuicatio skills. The project team received traiig from the NHS Istitute ad a cosultacy firm which specialised i lea maagemet. This traiig was the exteded to all ward maagers, givig them each a oehour sessio o the ature of the programme durig their developmet day. All registered urses were also offered a 45- miute traiig sessio o the programme. The traiig was fuded by the NHS Istitute. The PW programme was rolled out gradually over three years ad is ow i place across all of the Trust s 90 wards. There was a iitial debate o whether the programme should be implemeted o a volutary basis, or whether it should be rolled out by specialisatio. It was evetually decided to lauch the programme o a volutary basis. The project lead felt it was more effective to make PW volutary at the start, sice the commitmet ad motivatio of ward maagers is vital to the success of the programme. She also believed that, give the commo methodology ad aims of the programme, sharig learig ad best practice across sites ad specialisms would be a useful way to foster greater iteractio betwee staff durig the merger period. It was hoped that, oce some wards had started the programme, others would be coviced of the beefits of joiig. Ward maagers were ivited to a presetatio o the PW programme ad this led to 35 wards iitially voluteerig to participate. The PW programme is implemeted at ward level by each ward maager. Ward maagers are resposible for all areas of the ward, icludig esurig cliical stadards are maitaied, recruitig staff, overseeig staff developmet ad traiig, hadlig patiet complaits, health ad safety, budgetary issues ad represetig the ward at Trust level. I relatio to the PW, the ward maager s resposibilities are listed as: esurig all staff are aware of the priciples of PW, ad workig with the team to develop a culture of cotiuous improvemet ad sustaiability updatig performace data ad developig mothly actio plas with the team usig daily ward briefigs to focus the team o actios aroud safety ad quality reportig to the PW team to idetify potetial problems which may affect ward progress actively ecouragig ad supportig staff i gettig ivolved with process modules ad esurig the focus is o a whole-team approach to improvemets. Ward maagers are assisted i the implemetatio by the PW project team, cliical leads ad the practice developmet matros. These groups take resposibility for supportig ward maagers ad esurig they have the kowledge ad skills to implemet the modules, establishig liks betwee the PW programme ad other quality ad improvemet projects, ecouragig the sharig of best practice, measurig progress agaist the agreed project pla ad reportig o progress to Trust maagemet. The ward teams are resposible for: cotributig to mothly actio plaig ad suggestig ideas for improvig quality ad safety updatig ay data they are required to collect 5
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK gettig ivolved i all process modules ad takig the opportuity to make suggestios which may improve patiet or staff experiece Idividual staff members who lead each module, are resposible for esurig completio of all work i the allocated timescale ad updatig the ward maager o progress, as well as actig as a champio for that module to esure chages are sustaied. The PW programme ow ecompasses all of the hospital s 90 wards ad 4,000 urses. Whe a ew ward sigs up to the programme, the project team ru a 13-week course, devotig a half day each week to teach the ward maager the basic lea methodologies. Durig these sessios they ca talk to the maager about what eeds to be implemeted that week, ay problems that have bee ecoutered ad actio plas for the comig weeks. The project team has also begu to orgaise traiig days, accordig to the differet modules wards eed to implemet. Wards which are all carryig out the medicies module, for example, ca sed represetatives to traiig days, which amout to 3 study days over 6 8 weeks. The represetatives participatig udertake a half-day of traiig, the check back with their team ad retur with feedback o the ext traiig day. The Lead reported that this is useful for problemsharig ad collective problem-solvig. The PW programme also icludes a focus o the collectio ad aalysis of data. The project lead poited out that ward maagers allocate a budget of aroud GBP1 millio each year for operatig each ward but, prior to the itroductio of the programme, they were ot always doig this o the basis of clear data. Before the implemetatio of PW, ward maagers would receive much of their sickess data aggregated accordig to specialism. This meat that it was hard to assess the performace of idividual wards. Uder PW, maagers receive much more localised data, which ecourages them to take owership of it ad seek to improve. There was also a sese that the type of data collected prior to PW was quite egative, i that it was focused oly o sickess ad ifectio rates. This led to the itroductio of quarterly staff satisfactio surveys ad display of patiet experiece data, to highlight areas of positive performace. Chages have also bee made to the way i which data is preseted, to make it more accessible to staff ad patiets. The project lead poited out that urses used to collect data but they did ot always ow it or uderstad it. Nurses are ow offered clearer presetatio of data via the ursig dashboard ad patiet status at a glace, which charts ad colourcodes performace i key areas. Uder PW, each ward has also itroduced a performace board, which preset data o patiet safety ad experiece, efficiecy of care ad staff well-beig, visible to both staff ad patiets. I terms of the costs of implemetatio, the time ivested by the project team amouts to GBP80,000 per year. However, the Trust has ot costed the time ivested by idividual wards. The project lead felt that, despite the pressure these types of iitiatives face to geerate a cost beefit aalysis, this was ot somethig which had bee achieved successfully. She felt that, despite the close ivolvemet of the NHS Istitute durig the first 6 9 moths of programme implemetatio, the Trust would have beefited from ogoig support from the Istitute to measure the retur o ivestmet or aalyse beefits realisatio. The iitial cost beefit aalysis that had bee carried out had bee based o the rather sweepig geeralisatios of a rapid impact assessmet. 6
Reactios ad challeges Reactios to the implemetatio of the PW programme have geerally bee positive. Staff o both wards visited for this research had iitially bee slightly sceptical at the idea of yet aother iitiative, but accordig to both employees ad ward maagers, ward teams saw the beefits of the programme ad the processes have quickly become embedded i their way of workig; accordig to oe ward maager, they just embraced it. Staff did ot idetify ay particular aspects of the programme that worked better tha others, ad the lead suggested this was due to usig a commo methodology. Ward maagers were very positive about the support they had bee offered from the Trust ad the project team. However, the impact of the programme appeared to deped o the particular circumstaces ad size of each ward. Oe ward maager iterviewed did ot feel that the programme had had a substatial impact, as the ward team had already bee well orgaised ad there were oly 13 beds o the ward. The urses had quite specialised tasks so it had bee fairly easy to match up urses with the modules they should implemet (for example, the utritio urse implemeted the meals module). The secod ward maager iterviewed felt that the programme had made a more sigificat positive impact. This was a much larger ward of 27 beds, which could discharge betwee 60 ad 80 patiets per week. The ward maager had take over at the begiig of the implemetatio of PW, i Jauary 2010. He reported that, prior to his arrival, the ward had bee eglected ad was facig sigificat staffig ad fiacial problems. I this cotext, he believed that the PW had served as a useful tool for improvig efficiecy ad performace. The project lead also believed that the effects of the PW programme were ofte highly depedet o the type of ward ivolved ad the leadership offered by the ward maager. The mai challeges cited by iterviewees were fidig the staff time eeded for implemetatio ad sustaiig egagemet with the whole of the programme ad beyod. The project lead reported that there had bee few problems with the modules themselves but more i esurig staff have time to carry out the programme. Some wards have bee better at maagig time tha others, ad have attempted to schedule i staff time to complete modules, but there are still istaces of staff beig co-opted back ito ormal duties whe teams are short-staffed. However, oe ward maager reported that this became less of a issue oce practices became embedded ad less time was required. Aother challege was that of sustaiability: esurig that staff remaied egaged, practices stayed i place, ad that the uptake of modules cotiued. Oe ward maager had tried to address this by keepig the ward team iformed ad tryig to address their feedback. The project lead had also ru focus groups with participatig ward maagers. These highlighted that part of the problem with sustaiig module uptake particularly after the iitial 13 weeks traiig was that maagers ad staff urses did ot always kow how best to guide their teams through the modules. I respose, the project team bega to ru traiig o leadig a module, which ay participatig staff member could atted. Oe of the cliical leads has also put together actio learig sets for the ward maagers. The project lead believed the key to successful implemetatio of the PW is the commitmet of each ward maager to the programme. She felt that where the programme has ot goe well, it has teded to reveal weaker ward maagers. As a result there has bee some attritio of ward maagers with a few movig to other positios, but the lead stressed that it was sometimes hard to determie the reasos for this. Ward maagers who have struggled have bee offered oeto-oe coachig o leadership skills, ad the hospital has also attempted to buddy up maagers of high-performig wards with those who are havig problems. The project lead believed that some iitially mediocre ward maagers have improved dramatically withi the structure provided by the PW programme. I this cotext, both the lead ad ward maagers poited out it preseted a major challege where ward maagers have bee away for exteded periods of sickess absece or materity leave the programme suffered from the loss of a figurehead. 7
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK The lead also suggested that the hospital could improve the extet to which wards share best practice. There had bee some attempts to do this o traiig days, but this had ot bee as extesive as hoped. She poited out that i very large orgaisatios, commuicatio is always a challege. Fially, while the focus of the PW programme o processes at ward level had bee useful, the lead poited out that it could feel be a bit isular, i that it disregarded care pathways across the hospital. These are cosidered a vital aspect of hospital fuctioig because it is possible to have very efficiet wards, but iefficiet processes for patiet trasfers across wards ad betwee wards ad surgery. This has bee addressed through the Trust-wide Better for You project, which has sought to exted the lea priciples of the PW across all areas of the hospital. 8
Impact o employees Staff ivolvemet Much of the impact o employees is cetred o the chages to opportuities for staff ivolvemet. The project lead felt that this has traditioally bee a challege for the NHS, which has a very hierarchical structure. She poited out that the hospital employs 4,000 urses, ad every oe of them must have oe idea. However, util ow there have bee few opportuities for staff to make suggestios ad part of the PW programme has bee focused o how to capture these ideas ad brig them to fruitio. Both ward maagers highlighted the ew opportuities for staff ivolvemet as a positive outcome of the PW; oe ward maager believed it had bee the best thig about the programme. O the smaller ward, the maager estimated that at least 50% of staff are ow directly ivolved i implemetig chage. He felt that the most importat chage associated with PW was a more sesible divisio of tasks, which had ecouraged staff to take resposibility for their desigated areas ad helped to sustai the chages. The maager o the larger ward also felt that delegatig implemetatio resposibilities to staff had ecouraged more active egagemet ad positive outcomes. For example, while tryig to ratioalise the equipmet purchased, oe urse took resposibility for fluid orders. This urse the aalysed orders ad usage rates ad devised a checklist for esurig the ward was orderig sufficiet fluids at the correct time. The maager believed this was vital to embeddig practices: fudametally, they re the oes who ve got to work with the systems. I tryig to esure that all staff sustaied the chages, he had also delegated resposibility to several other staff members who were particularly observat ad therefore adept i idetifyig process improvemets. He poited out that if it comes from me all the time, they just switch off, ad that ivolvig other staff esures cosistecy i processes, rather tha just whe the maager is preset. Staff are also give more opportuities to offer feedback. Mothly ward meetigs iclude discussio of ideas for chage, ad documets such as the ward routie ad the ward visio are set out for commet. Whe a module is completed, staff are asked for feedback o the process, ad commets are the displayed for others to discuss. The maager of the larger ward believes that PW has give staff more opportuity to challege practices. Obviously, may areas are regulated by Trust guidelies, but PW has ecouraged staff to be clearer about the chages that ca be made o the wards. He also felt that it was his resposibility as a ward maager to offer staff ew ideas; he poited out that may staff had bee i post so log that they were less likely to questio their ow habits. I this sese, he felt that PW has bee very good for him as a ew maager, ecouragig him to thik about ad challege the old ways of workig. The maager o the larger ward also felt that a major factor i the extet of staff ivolvemet was the approachability ad attitude of idividual ward maagers: staff are kee to make suggestios because they kow I ll liste to it. Like the project lead, he argued that if the ward maagemet team does ot support the programme, othig will chage because they have to be receptive to ew ideas. Oe ward maager discussed the way his role as a maager had chaged i a more participatory eviromet; he felt his resposibility as a maager i helpig staff implemet ew ideas had shifted towards lettig [staff] ru with it but stoppig them if they re goig the wrog way. He also felt that maagers should provide staff with other optios, rather tha simply stoppig a practice that was ot workig. However, the project lead also stressed that these expaded opportuities for staff ivolvemet were still at the very early stages. She felt that chagig a orgaisatio takes time, ad much remais as future plaig. Staff developmet A further major impact of the PW programme was i providig opportuities for staff developmet. Oe ward maager poited out that delegatig module leadership resposibility ca ehace urses CVs ad icrease their cofidece. He gave the example of oe member of the ursig team whose cofidece was very low; he had therefore worked through the first module with her to show that she did kow what she was doig ad she was good. The project lead felt that 9
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK PW demaded a particular skills set, especially whe it came to service improvemet, assertiveess ad problemsolvig. She felt that urses fid these skills easy to apply to cliical care, but caot always trasfer them to more routie issues so PW had bee a useful tool i this respect. This could put staff i a better positio for promotio, although ogoig challegig fiacial circumstaces may limit the umber of promotio opportuities. Workig coditios There were some improvemets to staff workig coditios ad their work life balace. The maager of the smaller ward felt that the programme had ot had much impact o the work life balace of staff. However, o the larger ward the maager stated that, whe he started i the role, may staff reported that they had missed breaks or were late fiishig their shifts. This has ow chaged, with far fewer staff workig late or missig breaks. The ward maager felt this was importat ot oly for staff s work life balace but also for patiet safety, ad has bee supported by clearer procedures ad better commuicatio for patiet hadovers durig shift chages. It should be oted, however, that it is difficult to attribute this chage etirely to PW. Sice the ward was uder-performig whe the maager took over, over the past two years it has had a large iflux of 12 ew staff, which has eased capacity problems. Staff sickess absece has also declied both i the wards surveyed ad across the hospital. The maager of the larger ward reported that, whe he bega i the role, staff sickess absece was high, at 13%. It declied durig 2010, but has sice icreased, although this is largely due to oe staff member goig o log-term sick leave. The project lead also metioed that sickess absece had declied, ad felt that the improved data collectio uder PW has helped maagers to address the issue. However, she also poited out that a ew Trust-wide sickess absece policy was implemeted at about the same time as PW, makig its direct impact harder to estimate. Team-workig The PW programme had a limited impact o team-workig; the project lead poited out that, although PW process are desiged to improve team-workig, this may ot take place i practice. Because urses work variable shifts, there is a ew ward team every 12 hours, ad the team does ot always cosist of the same people. Small teams therefore exist for lie maagemet purposes, but workig teams ad their resposibilities chage daily. Oe ward maager felt that, although PW could ot stregthe teams themselves, it made staff more aware of workig i a team. Performace maagemet ad staffig The effect of the PW programme o performace maagemet ad staffig was limited, sice i may cases hospital regulatios took precedece. For example, there had bee o reported chages to pay structures, recruitmet, shift patters or staff turover. Appraisals are also carried out accordig to Trust guidelies ad have ot chaged. However, oe ward maager stated that the implemetatio of PW had provided maagers with a framework which allowed them to address performace problems o the spot, ow that there are better procedures aroud observatios or data collectio for example. 10
Impact o the orgaisatio The evidece suggests that the PW programme has had a umber of beeficial impacts for the orgaisatio, but also that these may ot always have bee the effects origially iteded. The recet focus o cost-cuttig i the NHS meas that PW s potetial fiacial beefits have bee a importat icetive. The project lead metioed that the origial pla was that the implemetatio of PW would allow the hospital to remove oe urse from each of its participatig wards. However, ultimately, this did ot take place. It was istead decided to keep the programme focused o quality of care, rather tha as a tool for staffig reductios. Three wards were evetually closed due to budget costraits, but they were selected o the basis of bed stock, rather tha their relative efficiecy i operatio. The PW programme lead reported that oe ward which was closed was, i fact, oe of the best performers i the PW programme. The ward maagers believed that savig moey was ot a major beefit of the programme, with oe statig that the most importat outcomes have bee icreased staff ivolvemet ad improved performace, rather tha fiacial beefits. The secod area that the PW programme was desiged to address was staff patiet cotact time; the programme s taglie is releasig time to care. However, while the project lead believed that the programme had eabled urses to sped more time with patiets, oe ward maager did ot agree. He argued that the programme had ot actually icreased the time urses spet o patiet care, but istead meat the care offered was of higher quality if staff were more coscietious as a result of havig proper breaks: if it meas that the urse has actually goe for her break, that beforehad she would t have goe for, if it meas that she s fiished her shift o time ad that everythig s bee doe properly, that observatios have bee doe properly the I thik it s bee effective. It may ot have meat more time at the patiet s bedside, but it s actually led to more efficiet ad effective care for that patiet. May of the orgaisatioal beefits discussed cetred o more efficiet workig practices ad workig eviromets. Both the maager ad particularly the employees o the larger ward felt that the opportuities provided by PW to assess the orderig ad storage of equipmet had bee a importat step forward. The maager poited out that, just by goig through the stockpile of ward equipmet they had maaged to get rid of 25% of stored items ad make orderig a more efficiet process ( we were a male urology ward orderig female catheters why?! ). The urses iterviewed cited the icreased space ad better orgaisatio as a major advatage whe carryig out their tasks, ad believed it had improved patiet safety. For example, the ward had previously oly used oe drugs trolley. This meat that by the time it had bee take to every patiet some medicies were ot beig admiistered at the correct times. Whe this was highlighted, the ward maager made a request for extra equipmet ad the ward ow uses three drugs trolleys to esure that patiets do ot have to wait for medicatio. The evidece suggests that PW also improves the experiece ad safety of patiets. Oe ward maager poited out that, although small, the observatios module had had a huge impact o patiet safety. He recalled seeig a patiet i May 2010 who had received o observatios for 36 hours but believes this would ever happe ow. Audits of safety issues used to be carried out oce a week, but are ow coducted every day. The maager felt that these improvemets were also reflected i patiet surveys: satisfactio rates have icreased ad are ow quite high. The ward has oly had oe registered patiet complait i six moths, despite dischargig 60 80 patiets per week a substatial reductio. Both the project lead ad maagers felt that a major elemet of performace improvemet attributable to PW is the ew focus o data collectio. The project lead felt that the more visual display of localised data was very powerful, ad had made figures easier for maagers to uderstad, ecouragig them to work towards improvemets. The Trust has see a improvemet of figures i a umber of areas: staff sickess rates have declied, cases of MRSA, C-Diff ad wardacquired pressure ulcers have reduced, although umbers of patiet falls remai a issue. The Trust s target for MRSA cases is five per moth; last moth there were oly three. 11
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK However, it is importat to ote that most staff highlighted problems of disaggregatio ad variatio i aalysig the effects of the PW programme. Sickess absece had reduced, for example, but this may also have bee liked to a recet stricter sickess policy implemeted by the Trust. Ifectio rates have falle, but there have also bee ew Trust guidelies i this area. Oe ward maager had recetly see a iflux of ew staff, which may have improved productivity ad workig coditios. It is also hard to separate the effect of PW from the umerous other improvemet iitiatives beig implemeted across the NHS, such as the Essece of Care bechmarks ad Nursig Quality Metrics. 12
Lessos leart ad future plas I geeral, both the ward ad project teams believed the programme had improved the performace of the hospital. Staff felt that patiet safety had bee improved, ad that there was better data collectio ad maagerial focus o key performace areas. Orgaisatioal culture was also chagig; the project lead believed that the programme was helpig to develop a orgaisatio that listes more to employees ad that puts processes i place to capture good ideas, ad recogised that this was quite a major chage from the previous culture at the Trust. She felt that the programme helped to break dow hierarchies ad to use staff as chage agets ad described leadig the PW programme as oe of the best opportuities I ve had i my ursig career. Both the project lead ad ward maagers felt that the impact of PW was heavily coditioed by the leadership ad coditios o idividual wards. The lead poited out that some wards have achieved far more through the programme tha others. This was largely determied by the attitude ad abilities of the ward maager, although the Trust has take steps to improve maagerial egagemet, such as buddyig effective ward maagers with those who are strugglig. Employee egagemet ad gaiig employee suggestios are fudametal ad critical to the success of the programme, but i order to elicit these maagers eed to be both competet ad committed to the ethos of the programme. Oe of the major challeges for the programme, both curretly ad i the future, is that its impacts are difficult both to idetify ad to distiguish from the cotributio of other complemetary schemes. There are may overlappig iitiatives i place ad all programmes take cosiderable time to become embedded. The project lead also poited out that ursig has traditioally bee full of hierarchy ad that this will be slow to chage. She felt there remaied a log way to go with the PW programme ad the switch to a lea model, but she was optimistic: look at Toyota. They ve take 60 years to get where they are ad we re i year three. The effectiveess of the PW programme has also ecouraged the Trust to expad its focus. The ward-cetred approach of the programme meat that the scheme ecessarily eglected care pathways (the stages of a patiet s care across differet areas of the hospital betwee admissio ad discharge). Therefore, oce the PW programme had bee i place for aroud a year, the hospital bega to expad the focus, ad to look at the ways i which improvemets to wholehospital practices could cotribute to the effectiveess of the PW programme. This kid of thikig cotributed to the developmet of the Trust-wide iitiative Better for You. The project lead believed that PW served as the foudatio for Better for You, with both beig based o the lea methodology. However, the wider iitiative was desiged iterally by the Trust rather tha the NHS Istitute. The Lead believed that the mai developmet of Better for You was that this iitiative works o a cross-fuctioal basis, to ecompass care pathways. It expads the focus o efficiet processes at ward level to look at the relative efficiecy of processes of referral across the hospital as a whole. As part of their bid to expad the uderlyig priciples of PW through the Better for You programme, the Trust has also attempted to create opportuities for greater staff ivolvemet outside the traditioal ward settig. The project lead explaied that they had recetly orgaised a series of gatherigs kow as the evets i tets. Marquees were opeed o the hospital grouds ad were accessible betwee 6am ad 10pm for two weeks, to cover all possible shift patters. Facilitated discussios took place about the PW programme ad the Better for You iitiative ad staff were offered the opportuity to make suggestios. Aroud 8,000 of the Trust s 13,000 employees atteded ad suggestios will be aalysed as the Better for You iitiative is exteded. The project lead reported that the Trust is also kee to allow for quicker reactio to staff suggestios. They had recetly lauched a iitiative kow as Just Do It, which will explore how staff ideas ca be quickly put ito practice. 13
Work orgaisatio ad iovatio: Case study: Nottigham Uiversity Hospitals NHS Trust, UK The icreased data collectio required uder PW has bee exteded ito the Better for You iitiative. This programme s broader focus has ecouraged staff to cosider the data which is ot always picked up at ward level. The project lead cited oe example as a focus o iteral waits. The Trust aalysed data o all iteral waits (e.g. for tests or X-rays) over a six-week period. This revealed that, o ay give day, 117 patiets have a day s wait. The lead poited out that the majority would still be i hospital, but that some could have bee discharged earlier if they had had a test or referral completed more quickly. The Trust is ow aimig to reduce iteral waits by 50%, ad has used the staff ad priciples ivolved i the PW programme to achieve this. Over the last four moths, the PW team have helped ward staff to use data already beig collected for performace boards ad patiet status at a glace to better idetify ad moitor iteral waits. The Trust s future plas to sustai the improvemets uder PW are therefore focused o a expasio of its priciples. As well as the implemetatio of Better for You, there are also plas to exted the iitiative to other areas icludig productive cleaig ad productive traiig. The commitmet ad egagemet of maagerial staff is viewed as the key to the success of these iitiatives ad the project team is cotiuig to focus o providig support ad advice for ward maagers. Refereces Europea Commissio (2008), Gree Paper o the EU workforce for health. Brussels, COM(2008) 725 fial. OECD (2012), Health at a glace: Europe 2012, available at http://www.oecd.org/els/health-systems/healthataglaceeurope.htm. Beth Foley ad Aette Cox, Istitute of Employmet Studies EF/12/72/EN 15 14