| Think beyond the immediate team | Although many nurses identified with Productive Ward, other staff groups were seldom engaged which undermined ongoing improvements to multidisciplinary processes. In focusing exclusively on ward and nursing processes, the original framing and format of the programme would not meet current demands for multidisciplinary teamwork and system transformation. Involving wider ward teams from the start could have helped mitigate risks to sustainability posed by staff turnover.
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| Ensure adequate resourcing for task completion and reflection | Funding was needed both to release staff from ward duties (so they could carry out Productive Ward activities) and to enable them to reflect on experiential learning in relation to the underlying principles of the programme (so they could then go on to apply them in changing contexts). The typical 2-year funding period was, in most cases, insufficient to enable implementation of all the modules as intended. A dedicated member of staff was needed to coordinate activities and ongoing training within organisations, as well as demonstrating organisational commitment to the programme. This role was key to realising sustained impacts.
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| Focus on quality not quantity | Take time to implement foundational modules fully and share lessons learnt and outcomes. As implementation progressed programme leads tended to run out of time and energy, and in later wards ‘solutions’ were imposed by programme leads and/or ward managers without giving other staff opportunities to identify solutions. This led to a sense of ‘being done to’ (rather than shared ownership). Focus on outcomes achieved or lessons learnt, rather than simply recording progress through a staged programme.
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| Less may be more | Productive Ward would have benefited from being more focused. The modules that were most frequently implemented were: the ‘Foundation modules’ (Well Organised Ward; Patient Status at a Glance; Knowing How We are Doing); followed by four of the process modules (Medicines; Meals; Patient Observations; and Shift Handovers). The remaining four process modules were rarely implemented in any meaningful way.
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| Play the long game | Adequate before/after and longitudinal data are required to demonstrate impact. Efficient local systems for enabling measurement of impacts and costs (initial and over time) should be built in from the start. The reputation of the Productive Ward suffered to some degree from overclaiming benefits at a national level without a sufficiently longitudinal or robust evidence base. Build considerations of sustainability and develop related guidance into the initial design and testing of a programme.
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| Adaptability | QI programmes need to be flexible. A programme such as Productive Ward needs to be able to absorb and adapt to changing organisational or system priorities so that relevant learning and resources can be applied to new priorities, rather than entirely new QI programmes being designed to replace or run alongside existing initiatives. Having guidance and toolkits available online where they can be revised and redirected, rather than hard copies of modules, would better support this.
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| Involve patients and carers as partners | Involve patients, carers and the public. Although guidance suggested roles for patients, visitors and patient representatives at ward and hospital level, such involvement was generally low to non-existent. Recent interest in—and examples of—how co-production can underpin QI work hold important lessons for meaningful and imaginative ways in which service users can and should be part of designing and evaluating programmes like the Productive Ward.
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