2008/2009
SOUTH CANTERBURY
DISTRICT HEALTH BOARD
PROPOSAL FOR THE SIX MONTH
IMPLEMENTATION PHASE OF RELEASING
TIME TO CARE
- THE PRODUCTIVE WARD MODEL IN
ADULT INPATIENT SERVICES AT SCDHB
[BUILDING STRONG FOUNDATIONS & SUSTAINING CHANGE]
Implementing a structured, health related approach to utilise the principles of ‘Lean Thinking’. This
proposal supports the lean philosophy and offers a credible structure that engages front line clinical
staff to take control and improve the clinical environment for the betterment of patient care (who
remain the focus in this approach) but also for themselves.
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RELEASING TIME TO CARE – THE PRODUCTIVE WARD]
RELEASING TIME TO CARE – THE PRODUCTIVE
WARD
1.0 Background
2.0 Risk Minimisation
3.0 Desired Outcomes
4.0 Proposed Process
5.0 Options
6.0 Success Barriers/Factors
7.0 Cost
8.0 Key Performance Indicators
9.0 Recommendation
10.0 Appendix
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1.0 Background
In 2006 a clinical tool kit named the
Releasing Time to Care – The Productive Ward was
published by the National Health Service Institute for Innovation & Improvement in the UK. In
August this year the Clinical Nurse Manager for the AT&R unit joined a small group of selected
roles from across nine DHBs to attend the master training course on this model in Manchester,
UK. This training opportunity and associated travel costs was funded by the Ministry of Health
with the expectation that participating DHBs would return and implement this methodology in a
selected service.
Releasing Time to Care - The Productive Ward model supports the principles of lean thinking1
which is also the basis of the national Quality Improvement Committee (QIC),
Optimising the
Patient Journey initiative. The Releasing Time to Care - The Productive Ward model offers a
systematic way of delivering safe, high quality care which focuses on patient flow, elimination of
waste, reduction of non-value patient activity and standardisation of process. Through the
achievement of these key outcomes an increase in time for direct patient care enables clinicians
to create and maintain safe and more reliable care systems as well as improving both workplace
staff satisfaction and morale.
There are 4 key dimensions which form the foundation for this model:
1. improved patient safety and reliability of care
2. improved patient well being
3. improved efficiency of care
4. improved staff well being
In October this year an interested group of staff visited Canterbury DHB to view their Releasing
Time to Care – The Productive Ward pilot in action. Discussions with front line staff in
Christchurch demonstrated the obvious level of ownership of practice and environmental
changes achieved to date and verified the user friendliness and acceptance of this approach in
empowering staff to initiate improvements.
2.0 Minimisation of current risk factors through implementing the Productive Ward model
Empowerment of staff to act i.e. implement small changes without seeking permission
results in issues being addressed or opportunities for improvement realised more
quickly. This model provides staff with the tools to affect change which in turn creates a
culture of continuous quality improvement
Initiation of staff suggested solutions and ownership of change by front line staff
increases the chance of a successful outcome
Streamlining routine activity increases direct patient care time e.g. observation frequency
and the detection of the deteriorating patient
Communication issues relating to the patient’s plan of care especially in relation to
preparedness for discharge are addressed
Standardisation of process, equipment and layout allows the safe mobilisation of staff
between units
1 The term Lean thinking is reference to the NHS adaptation of the Toyota way for application in the health system
and is wholly based on the principles captured in that production plan methodology.
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Transparent information i.e. the open display of performance and clinical indicator data
creates a culture which supports open disclosure and professional debate which in turn
engenders public confidence
Satisfaction for staff improves morale and reduces staff turnover, which in turn reduces
costs, associated with recruitment and orientation. Consistency in the health team also
improves efficiency and reduces the potential for clinical error
Reduced incidence of complaints as all staff are involved in providing an efficient service
to the patient and are aware of their roles within the team
3.0 Desired outcomes from implementing the Productive Ward model
To create a culture which affirms the key principle that the patient’s time is the most
important
To reduce patient incident rates
To develop teams of self starting, self managing staff empowered to act i.e. quality
improvement activities done by staff rather than to staff or with staff
To increase the amount of direct care time spent with the patient i.e. value added
activity, allowing patients to get better, quicker
To identify and eliminate all forms of waste in the ward setting
To improve patient levels of satisfaction
To reduce patient length of stay
To review how ‘work is done’ and determine the more appropriate model of nursing care
for the setting
To facilitate the ‘patients voice’ during any process redesign
To educate and equip all staff aligned to the ward with tools to identify, affect and
monitor improvement
To develop a system where maintaining high quality and continuous improvement is a
part of everyone’s day to day working practice
To improve staff levels of satisfaction and reduce staff turnover
To improve clinical leadership, teamwork and communication within the clinical setting
4.0 Proposed Process
Implementation requires the following three main management, coordination/education and
facilitation positions
Project Manager who provides the strategic direction and overview for the project. This
will be encompassed within the General Manager Quality & Risk current role.
Project Leader who introduces and coordinates the release of the model to selected
wards, educates staff in the tool set and provides support and advice for the clinical
champions. It is proposed to second the Clinical Nurse Manager of the AT&R Unit who
undertook the training to fill this role.
Clinical Champion working in the clinical setting who are a senior registered nurse in
each ward, engaged in the project who facilitate defining a vision for the ward,
undertaking the diagnostics in their respective areas, coordinating planned changes to
the environment or staff practice and monitoring and evaluating to assess that any
change implemented is in deed an improvement
A set of baseline tools will be utilised at the introduction of the model to each ward. These
relate to patient satisfaction, staff satisfaction, safety climate and selected performance
measures baseline data. This information establishes the platform for change and allows
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comparative information to evaluate the success of the project. The toolbox includes three
diagnostic modules, which includes all the tools required for capturing data/information as well
as a number of patient related activities, which provide guidance in affecting change. A
diagrammatic representation of this is attached for you information (refer appendix 1).
It is proposed that the implementation of Releasing Time to Care – The Productive Ward is
phased as follows:
AT&R ward February – July 2009
Medical ward April – September 2009
Surgical ward June – November 2009
These will run simultaneously with the local Optimising the Patient Journey project on
Timeliness of Discharge Summaries which is currently underway to meet the requirements of
the scheduled national collaborative learning events. It is also unknown at this stage whether
additional quality improvement activity will be required with the implementation of phase two of
the national Optimising the Patient Journey Initiative – Primary/Secondary interface for Chronic
Conditions due to be launched in February 2009.
5.0 Options for ward selection
1. Implement Releasing Time to Care – The Productive Ward model in the 24 bed medical
inpatient ward only
Benefit: Focused resource approach. Minimises risk of distraction associated with change to
one clinical site.
2. Implement Releasing Time to Care – The Productive Ward model in the 24 bed medical
inpatient ward and the 24 bed AT&R unit simultaneously
Benefit: Standardisation of approach across the medical continuum to maximise combined
impact in two closely related teams. Peer support for clinical champions between the two
selected wards.
3. Implement Releasing Time to Care – The Productive Ward model in the 24 bed medical
inpatient ward, the 24 bed AT&R unit and the 40 bed surgical ward simultaneously
Benefit: Standardisation of approach across all adult inpatient wards. Extended peer support
and combined learning opportunities for clinical champions. All personal health inpatient units
regarded as equal to the opportunity for change and improvement. Demonstrates complete
organisational commitment to Releasing Time to Care – The Productive Ward model.
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6.0 Success Barriers/Factors
Timing of the implementation phasing should option 2 of 3 be selected
Staff buy-in and commitment to process
Staff training in the model and associated tools including ability to source external
training providers
Maintaining clinical leadership capacity
Sustainability of process improvements following implementation phase
7.0 Six month Implementation Phase costs for each option are outlined below:
Advice has been received from the Ministry of Health that we are assured a minimum of 24 free
licenses (i.e. one ward). This number may increase dependent on national DHB demand for the
1000 licenses purchased by the Ministry of Health. Additional licenses are available for
purchase at $48/bed.
Option 1 – Medical inpatient ward only
SMO
0.2 FTE
4 months
$16,000
Productive
Ward
0.5 FTE
6 months
$ 24,000
Leader
Clinical Champion
0.5FTE
6 months
$ 20,500
Productive
Ward
MoH funded
One off
-
Licenses
Training
Provider
Estimated
One off
$6,000
costs
Sundry
Release time for
$12,000
staff training,
equipment, facility
alterations
Total cost of option 1
$78,500
Option 2 – Medical inpatient ward and AT&R wards
SMO
0.2 FTE
4 months
$16,000
Productive
Ward
0.5 FTE
9 months
$36,000
Leader
Clinical Champion
1.0 FTE
6 months
$41,000
Productive
Ward
$48/bed for 24
One off
$1,152
Licenses
AT&R unit
Training
Provider
Estimated
One off
$13,000
costs
Sundry
Release time for
$24,000
staff training,
equipment, facility
alterations
Total cost of option 2
$131,152
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Option 3 – medical and surgical inpatient units and AT&R unit
SMO
0.2 FTE
4 months
$16,000
Productive
Ward
0.5 FTE
9 months
$36,000
Leader
Clinical Champion
1.5FTE
6 months
$61,500
Productive
Ward $48/bed for 24 bed
One off
$3,072
Licenses
AT&R unit and 40
bed surgical
inpatient unit
Training
Provider
Estimated
One off
$19,500
costs
Sundry
Release time for
$36,000
staff training,
equipment, facility
alterations
Total cost of option 3
$172,072
Consideration will also need to be given to educator and administrative support required from
the Staff Development Unit in the roll out of the staff education aligned to implementing this
model. Budget has been included for contracted external training resource. It is anticipated that
this may be sourced from CDHB.
Following the initial trial period it is anticipated that a successful implementation phase would
release in the selected ward/s involved in the implementation phase for active participation in
quality activities.
Performance and clinical indicator auditing which is essential for the monitoring sustainability of
improvements is already a requirement for Clinical Nurse Managers with responsibility of
maintenance of implemented processes absorbed within this role.
8.0 Key Performance Indicators
Measurement of the desired outputs that will arise from implementation of the Releasing Time to
Care – The Productive Ward modules are considered under the four key outcomes of the
model.
The targets set for either increasing or reducing rates following analysis of baseline data by
ward
1. Improved patient safety and reliability of care
< % of patient falls
< % of blood stream infections
< % of medication errors
2. Improved patient experience
< % of consumer complaints relating to service provision and discharge planning
> % of patient satisfaction for selected criteria
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3. Improved efficiency of care
> % direct patient care time
< average patient length of stay
> % of patients who are discharged before 1200hrs
< variance between actual date of discharge against planned date of discharge
< % medical patients who overflow to the surgical unit, impacting on the ability to
conduct elective surgery
< cost monitoring of ward consumables, therapeutics etc
4. Improved staff well being
> % staff satisfaction for selected criteria
= % staff turnover
< % unplanned staff absences
9.0 Recommendation
SCDHBs accepts and aims all improvement activity to meet the definition of quality as follows:
“Doing the right thing for the right person, at the right time and getting it right first time and every
time”. Donaldson & Gray 1997.
It is proposed that adoption of the Releasing Time to Care – The Productive Ward model fully
supports this philosophy and offers a credible structure that engages front line clinical staff to
take control and improve the clinical environment for the betterment of patient care (who remain
the focus of this approach) and for themselves. Positive results have been reported both from
the UK experience and more importantly early indications from the CDHB pilots are also most
encouraging. CDHB has indicated that they are wil ing to provide advice during SCDHB’s
implementation of this model.
SCDHB is committed to engaging in the national Quality Improvement Committees initiatives
including the one relating to Optimising the Patient Journey. As we were unsuccessful in our
application to be a pilot site for the
Whai Manaki programme and associated coaching resource
The Releasing Time to Care – The Productive Ward model provides an alternative approach to
meeting the intent of this national initiative. This model provides a more structured, health
related approach to utilising the principles of lean thinking which underpin this national initiative
and can be utilised to meet our obligations for participation in this national initiative.
Timing of the implementation phasing is a major success factor that requires consideration
should option 2 or 3 be selected. From the CDHB experience it can be noted that careful timing
of their roll out and the selection of pilot wards were critical considerations in their success. In
order to consolidate the critical mass of staff buy in at SCDHB it is recommended that the
Clinical Nurse Managers of the Medical and Surgical wards visit CDHB and spend some time
with staff on those wards engaged in their pilot to gain an overview of the model in action.
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As the Clinical Nurse Manager has been trained as a ‘Master Trainer’ in The Releasing Time to
Care – The Productive Ward it is recommended that she be seconded for a period of six months
to fill the role of project leader.
It is recommended that approval is granted for the implementation of option 3 (medical, ATR
and surgical inpatient wards) as this option demonstrates a complete organisational
commitment to The Releasing Time to Care – The Productive Ward.
03 December 2008
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