The Atlas of Shared Learning

Case study

The Exemplar Ward – Nurse led quality improvement at University College London Hospitals

Leading change

The nurse leadership team at University College London Hospitals (UCLH) have developed an Exemplar Ward programme with other colleagues across the Trust. This programme is designed to support clinical teams to implement standard processes, reduce unwarranted variation and deliver local quality improvement initiatives in their wards and departments. Data packs and monthly trend reports allow staff to view at a glance how their ward is performing, identifying what is being done well and what needs to improve. UCLH are beginning the move from reactive use of information towards a more proactive and preventative approach. This will help ensure that patients receive quality care at all times and that staff work in a culture that supports and motivates them to engage in continuous improvement.

Where to look

International evidence demonstrates that accredited hospitals and wards have better outcomes and better staff retention. Along with nurse leaders at UCLH, a committed collective of clinical staff, patients and researchers joined forces to define what the ‘outstanding wards’ at UCLH would look like – and the Exemplar Ward accreditation was developed. The nurse leadership team recognised from clinical audit data that there was unwarranted variation across the organisation. Prior to the Exemplar Ward, the teams were delivering good care, but they weren’t always able to evidence it in the way they would like, and also it wasn’t the same across wards.

The Exemplar Ward programme was designed as a platform for continuous quality improvement using a practical accreditation model. By scrutinising ward data closely, it aims to improve the ward environment in 4 ways:

  • By standard setting;
  • Providing meaningful information for ward teams to monitor their progress;
  • By creating constructive conversations to enhance the team work around improvement;
  • Recognising and rewarding success.

What to change

A key change for the Chief Nurse at the head of this programme is the quality metrics that used to be viewed on a month by month basis focused on exception reporting – what isn’t going well that month – rather than focusing on trends for wards. The Exemplar Ward programme now sets out to bring all of the quality metrics together to provide a monthly ward report, which allows data to be truly scrutinised and demonstrate what is going well and areas in need of change.

The organisation as a whole has committed to a culture change in supporting approaches to continuous improvement, to use data to drive efficiency and to drive innovation and improvement forwards – collaborating and learning from other wards in the Trust.

How to change

The Exemplar Ward accreditation programme sets out 5 key pillars: Quality and safety; Efficiency; Patient experience; Staff experience; Improving.

The nursing leaders empowered clinical staff by bringing the data together in one place with the ward sisters being charged for leading the quality improvement initiatives that resulted. For example, on the Thoracic Ward, the ward sister introduced a 3pm huddle to focus on patient safety improvements. Part of the accreditation programme is to support the team to understand and engage with the project to identify that it can make a big impact on patient and staff experience. The Exemplar Ward programme sets out to give ward leaders, as well as all staff, wherever they work, whatever their role, the core skills in quality improvement.

The accreditation model contains three levels of accreditation – good, great, and outstanding – in recognition of significant milestones along their journey to excellence. For patients and their families, the Exemplar accreditation signifies exceptional care through improved outcomes and greater overall satisfaction. For clinical staff, Exemplar accreditation means a positive and supportive work environment with greater collaboration between colleagues and leaders, higher morale and lower turnover. Exemplar accreditation provides an overall score that reflects how a ward is functioning in the five fundamental areas.

There are seven steps towards Exemplar Ward accreditation: 1) reviewing the data and setting an annual improvement plan, 2) annual assessment, 3) panel interview, 4) results, 5) next steps, 6) Continuous quality improvement, 7) Rewards and recognition.

Adding value

  • Better outcomes –The Exemplar accreditation model was finalised following a year of testing that included application of the scoring model across 37 wards and ongoing development of assessment approaches. There has been a marked improvement in the number of pre-12pm discharges, and an increased awareness of the importance of multi-disciplinary teamwork and planning to facilitate efficient patient discharge.
  • Better experience – Experiences have improved as a result of the exemplar ward programme. Staff responses included:

“The accreditation assessment has given us data that is understandable and much easier to share with the team. This was hard, however we now have a clear indication of where we are and where we need to get to.”

T7 Ward sister.

“At first I was apprehensive as I felt this rolling roster might be restrictive, but it had the opposite effect. I was able to plan my life for the entire year. It also meant it was fair; everyone works nights and two weekends so I don’t ever feel hard done by!”

Staff nurse CCU.

  • Better use of resources – The Exemplar Ward has strengthened the role of the ward sister, staff nurses, the matron’s role; they are all in this, whether it has been designing the metrics, whether it has been about helping design the way the panels and assessment programmes run at the Trust, by contributing expert knowledge to what has and hasn’t worked well. The quotes above reflect this observation. With regard to pre-12 noon discharge, there is an estimated saving across Quarters 1-3 of £162,132. The Exemplar Ward approach has also led to achievements in:
    • An overall cost benefit of >1 million from nursing and midwifery staffing costs
    • 37 wards assessed for baseline accreditation
    • An increase of 4% in pre-12 noon discharges
    • Improved nursing assistants’ confidence by up to 74%

Challenges and lessons learnt for implementation

  • Small things make a big difference to patient care – fundamental differences to delivery of care and can be embedded as business as usual;
  • The Exemplar programme is a way to structure what is happening and measure improvements. Exemplar ward improvement course – to give staff coaching to implement improvement work and empower them to lead change;
  • The co-design ethos of the programme is maintained and continues through interactive workshops with the Programme Board and others.

“As Chief Nurse, I know the desire of staff to deliver the highest standard of care for our patients; the same quality of care we expect for those we care about. I am delighted that we’ve already completed the first year of our ward accreditation programme. During the second year, we will continue to build on our culture of continuous quality improvement and support the understanding of ward performance from ward to board.”

Flo Panel Coates, Chief Nurse and Executive Sponsor of the Exemplar Ward at UCLH.

Find out more

For more information contact:

  • Natasha Phillips, Chief Nursing Informatics Officer and Programme Lead Exemplar Ward Programme, UCL Hospitals NHS Foundation Trust,