Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme in English acute hospitals

Robert, Glenn; Sarre, Sophie; Maben, Jill; Griffiths, Peter; Chable, Rosemary

doi:10.1136/bmjqs-2019-009457

Cited by 59 publications

(40 citation statements)

References 16 publications

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“…In the face of staff shortages, it is tempting to consider alternative approaches for improving the effectiveness or efficiency of the current workforce. Although there is scant evidence for improved productivity arising from quality improvement initiatives, such as the Productive Ward programme, 151,152 or structural changes, such as altering shift patterns, 146 the importance of quality leadership and management in ensuring an effective and productive ward nursing team is largely beyond dispute. However, without dismissing the importance of such factors, they serve merely to remind that having enough staff is necessary but not sufficient.…”

Section: Results In Contextmentioning

confidence: 99%

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Griffiths

Saville

Ball

et al. 2020

Health Serv Deliv Res

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Background The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care. Objectives To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure. Design This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand. Setting Medical/surgical wards in four NHS hospital trusts. Main outcome measures The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved. Data sources The data sources were hospital administrative systems, staff reports and national reference costs. Results In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000. Limitations This was an observational study. Outcomes of staffing establishments are simulated. Conclusions Understanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function. Future work Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible. Trial registration Current Controlled Trials ISRCTN12307968. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

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Section: Results In Contextmentioning

confidence: 99%

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Griffiths

Saville

Ball

et al. 2020

Health Serv Deliv Res

Self Cite

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“…While QICs have been studied extensively, implementation has differed and outcomes have been inconsistent (7, 56). Few studies have used a realist approach (30) or explored the use of collaboratives to improve quality in dementia care (31).…”

Section: Discussionmentioning

confidence: 99%

How, Why and Under What Circumstances Does a Quality Improvement Collaborative Build Knowledge and Skills in Clinicians Working With People With Dementia? A Realist Informed Process Evaluation

Perrelle

Cations

Barbery

et al. 2020

Preprint

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In increasingly constrained health and aged care services, strategies are needed to improve quality and translate evidence into practice. In dementia care, recent failures in quality and safety have led the World Health Organisation to prioritise the translation of known evidence into practice. While quality improvement collaboratives have been widely used in healthcare, there are few examples in dementia care. We describe a recent quality improvement collaborative to improve dementia care across Australia and assess the implementation outcomes of acceptability and feasibility of this strategy to translate known evi-dence into practice. A realist-informed process evaluation was used to analyse how, why and under what circumstances a quality improvement collaborative built knowledge and skills in clinicians working in dementia care. This realist-informed process evaluation developed, tested, and refined the program theory of a quality improvement collaborative. Data were collected pre-and post-intervention using surveys and interviews with participants (n=24). A combined inductive and deductive data analysis process integrated three frameworks to examine the context and mechanisms of knowledge and skill building in participant clinicians. A refined program theory showed how and why clinicians built knowledge and skills in quality improvement in dementia care. Seven mechanisms were identified: motivation, accountability, identity, collective learning, credibility, and reflective practice. Each of these mechanisms operated differently according to context. A quality improvement collaborative designed for clinicians in different contexts and roles was acceptable and feasible in building knowledge and skills of clinicians to improve dementia care. A supportive setting and a credible, flexible, and collaborative process optimises quality improvement knowledge and skills in clinicians working with people with dementia.

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“…Recent large-scale studies in Uttar Pradesh have shown both the potential to change some common practices among both clinical and non-clinical staff, and highlighted the high cost and long-term investments needed to effect those changes [18,19]. The Quality Improvement (QI) literature has documented both the sustained effect, and the gradual change and simplification of interventions over time in hospital settings [20]. Team-based QI interventions demand significant time and resources commitments and so there has been experimentation in many settings with "Light Touch" variations [21][22][23][24].…”

Section: Challengementioning

confidence: 99%

A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

Montagu

Giessler

Nakphong

et al. 2020

BMC Health Serv Res

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Background Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. Methods We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome Results Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. Conclusions This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial registration QI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. QI Phase 2 –NCT04208841. Retrospectively registered. December 23, 2019.

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Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme in English acute hospitals

Cited by 59 publications

References 16 publications

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

How, Why and Under What Circumstances Does a Quality Improvement Collaborative Build Knowledge and Skills in Clinicians Working With People With Dementia? A Realist Informed Process Evaluation

A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

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