Table 2

Changing forms of assimilation over time (with illustrative examples)

Hospital	Form of assimilation at time of fieldwork (up to 10 years post-adoption)	Post-implementation (typically year 2 onwards)	Form of assimilation during implementation (typically years 0–2)
A	Customisation Whole hospital transformation programme inspired by Productive Ward Hospital-wide system of shared governance to capture staff suggestions on QI	Former facilitators re-deployed to other projects Wards felt that Productive Ward no longer a Trust priority Evolution: of Patient Status At a Glance to e-system; Knowing How We are Doing boards re-evaluated; shift to Accountability Handovers; revisiting processes (some wards)	Transformation All wards implemented most modules Standardised Efficient storage system throughout hospital; better stock management; designated areas for equipment; extra equipment purchased Knowing How We are Doing and Patient Status At a Glance boards on all wards Greater staff voice in QI and increased familiarity with data
B	Customisation Still part of nursing development lead remit; ad hoc support given to wards by original lead Two ward managers continue to have protected time (1 day a month) Other wards continue to revisit processes, though not using Productive Ward tools Hospital-level discussions underway re-improving use of ward-level data and display	End of funding for leads although continued to support Remaining wards implemented after initial 2-year implementation period Storage overhauled post-implementation Impacts on wards sustained for 1 year Became part of remit of nursing development lead Two ward managers given protected time (1 day a month) to implement on their wards	Transformation All wards implemented three foundation modules and at least four process modules ‘Direct Care Time’ reportedly increased in most wards by 15%–20% Standardised efficient storage system; better stock management; designated areas for equipment; extra equipment purchased Knowing How We are Doing and Patient Status At a Glance boards on all wards Greater staff voice in QI
C	‘Loose coupling’ (see text) ‘Trust Quality Bundle’ still being implemented and developed. But evidence that ward manager-led (rather than teams); modules seldom rerun Poor reach of staff involvement in QI Standardised Knowing How We are Doing boards still being used (but out of date) Productive Ward storage still in place	Developed a QI ‘bundle’ (‘Trust Quality Bundle’), which used Productive Ward as a framework but incorporated relevant elements of other QI programmes Introduction of Datix web-based incident reporting and risk management software in place of Safety Crosses	Customisation Limited number of modules implemented ‘Direct Care Time’ reportedly doubled Knowing How We are Doing boards introduced on all wards; data not used Patient Status At a Glance boards, standardised meals processes/protected mealtimes introduced to all wards Storage and stock control improved
D	‘Loose coupling’ (see text) Display and use of data embedded; Safety Crosses still used Electronic Patient Status At a Glance, and standardised Knowing How We are Doing boards still in use Influence on ongoing QI work Lean training available to all staff Limited junior staff engagement with QI	Continued for 12 months Shift handover evolved and ‘Trust Way’ equivalent of Knowing How We are Doing was increasingly tailored to ward New board members marked shift to different QI programme. ‘Trust Way’ leads re-deployed; standard Knowing How We are Doing Boards introduced	Customisation Hospital developed own QI tool (‘Trust Way’); consisted of adapted versions of the foundation modules and sustainment process Trust Way extended to non-ward areas Standardised shift handover and protected mealtime policies introduced Poor engagement of junior staff Changes made to physical environment
E	Loose coupling Non-standard Knowing How We are Doing and Patient Status At a Glance boards in all wards Safety Crosses still used on some wards, but in some cases ritualistically (not clear or regularly updated) Some ward managers continued to use Productive Ward principles and QI skills	Initial implementation period extended for a further 12 months Implementation team then re-deployed Widespread reorganisation of wards in one hospital, along with staff shortages meant wards there stopped implementing No wards reran any modules once the team had been redeployed	Loose coupling No strategic patient public Involvement Limited number of modules implemented Poor engagement with junior ward staff Training given to ward managers only Standardised Patient Status At a Glance boards Changes to physical ward environment Some processes standardised
F	Loose coupling Well Organised Ward principles still evident Standardised Knowing How We are Doing boards in all wards but in some cases ritualistically (not relevant or not regularly updated) Safety Crosses still used on some wards, but in some cases ritualistically (not clear or regularly updated) Some ward processes still in place Evidence of ward staff involvement in continuous QI	Operational group set up at the end of the implementation period Productive Ward reported as pivotal in Trust’s decision to set up a QI department Physical infrastructure of the new hospital: Increased mileage walked by ward staff and time spent away from direct care; additional equipment bought to compensate for offward storage Patient Status At a Glance was developed into an electronic system Admissions and discharge work was further developed	Co-optation Implementation shaped by requirements of new building (standard layout of wards; single rooms so bedside handover required) Only wards due to move to new building included in roll-ut plan Limited number of modules implemented Wards told which modules to implement Standardised Knowing How We are Doing and Patient Status At a Glance boards introduced to all wards Standardised changes made to storage and stocktaking

QI, quality improvement.