The Design Process 1 The ‘refresh’ project

In order to promote the use of SystmOne, IM&T had developed a network of SystmOne ‘clinical champions’ who were based in the services already using the system. The clinical change facilitation team met the champions regularly who provided feedback on the use of the system and made many suggestions for improvements to the system. One of the clinical change

facilitators described the state of their office as these requests accumulated.

So we have got – we call it our’ wallpaper’ in our office – a lot of flipcharts which make sure we keep sight of all the wants and needs that have come in.

Clinical Change Facilitator The clinical change facilitators contrasted the bottom up process of dealing with these requests with the top down ones which came via the commissioners. The process of reviewing bottom up suggestions was partly about getting support for them from other stakeholders, partly about the resources involved, partly about technical feasibility and partly about not compromising the safety and integrity of the system. Information governance staff of the PCT reviewed the impact of any proposal for change for risks to safety and integrity. The issue of what could be changed locally from a technical perspective was often problematic because SystmOne only permitted certain kinds of changes to be made. More fundamental changes had to be ‘escalated’ and could take a long time.

As a result of reviewing requests by community stakeholders, the IM&T department had established an internal project to deal with a number of them in an integrated change programme called the ‘refresh project’ whose main aim was to reduce the 5,000 templates currently used across the 22 community services to about 100. The aim was to standardise the templates for commonly used assessments and care plans to simplify data input, avoid needless replication and help information sharing. Alongside the standardisation objective was the objective of moving forward with mobile working by identifying key workers who would most benefit from laptops and setting up trials for them.

The project was planned for 8 months (April – December 2010) in three phases. It would begin with District Nurses but then extend to the 22 services using SystmOne. The project team used some of the processes within PRINCE2 to manage and document the project but considered that the full methodology would be too ‘heavy’ for a small project of this kind. The three phases of the project were:

Phase one - an assessment of the ‘as is’ processes in use in SystmOne

for the assessments and care plans in the services. Clinical change facilitators shadowed the clinical staff of the services and logged the various care plans in use.

Phase two - configuring new templates and testing them with users. It

was also the phase in which new reports could be designed to map onto the needs of kpi’s and a new mobile working trial was planned. The team were beginning phase two at the time of the interviews and gave

us the opportunity to observe design meetings held in this phase (see section 8.2.4.2 below).

Phase three - the training and trial phase including ‘go live’ with the new

templates.

8.2.5.2 Meetings of the ICT Refresh Team

Monthly meetings of the ICT refresh project design team were held in the summer of 2010. The first, attended by three members of the clinical change facilitator team, discussed progress in formulating templates for three assessment and care plans in intermediate care. Nurses wanting alternatives within templates but managers wanted only one version of the template to better serve the collection of data against kpis. It had been agreed that the nurses doing the assessment of patients referred to ICT were in most need of mobile working and the team considered how to deploy ‘tough’ laptops to them for a trial period.

The second meeting of the team led to a major change of direction of the project. It was attended by two ICT service development managers. Originally the meeting was called to review the kpi targets for ICT services and what they meant for reports generated by SystmOne. However, the service development managers reported that ICT had made a successful business case to the commissioners within the national QIPP (Quality, Innovation, Productivity and Prevention) initiative to develop ICT so that it could play a more substantial role in avoiding admissions to hospital and managing care in the community especially for elderly patients. This development meant there was new urgency to deliver the SystmOne changes and also changed priorities. Staff numbers in ICT would be expanded, as would the number of beds, and the pathway for care was being re-designed. The commissioners wanted the new pathway ready for winter so plans needed to be in place by end of September.

The service delivery managers asked that the changes in templates for ICT be implemented in September rather than December and that ICT now receive the full attention of the design team. The change facilitators agreed to delay developments for other services and ‘Wheelchairs and Falls were dropped’. The service development managers also said that templates should be standardised for ICT alone without reference to other services and that ensuring data was collected in the form that enabled reporting against the new kpis for the service had to be a priority. One of the clinical change facilitators reflected after the meeting that the focus on supporting individual clinicians seemed to have been lost in favour of managing the new pathway. Other teams were working on pathway redesign and on organisational changes, e.g. on creating a single point of referral into the service and a much greater role for administrative staff. The service development managers also asked that the trial of laptops for

mobile working be replaced by an exploration of the locations where ICT staff could ‘drop in’ and use computer facilities to access SystmOne.

Subsequent to the meeting, the refresh project changed its scope and timescale to give the ICT project priority and rapid progress was made in developing the two specific templates that were required: for admission avoidance and to facilitate early discharge respectively. At the third monthly meeting the team were joined by an ICT nurse with responsibility for team facilitation and a community matron. One of the items on the agenda was ‘training the trainer’ for the adoption of the new templates because the training of all ICT staff was scheduled for the middle of September. However, the main issues debated were the implications for SystmOne of a revised kpi reducing the target length of stay of patients on the pathway from 14 days to 5-7 days. The implication for the service managers was that they had to be very resource efficient and they wished to put electronic scheduling back on the agenda.

Thereafter, it was planned to hold weekly meetings in order to make the rapid progress necessary for delivery in September.

8.2.5.3 Reflections on the Refresh project

Interviewed in December when the refresh project was due to finish, one of the clinical change facilitators reported that after a 3 month period in which there was a real impetus to the project and everything was done to develop SystmOne facilities to serve the new ICT pathway, the momentum had been lost and various aspects of the project remained ‘in the air’. The regular meetings had been discontinued mainly because ICT were too busy with other planning to attend. Implementation also tailed off because the peer trainers who were going to train their colleagues could not be trained. Nevertheless template configurations had been completed and were ‘signed off’ by the users. There were however, a lot of loose ends to tidy up and the consequences of the new pathway for SystmOne had not been properly explored.

During this period the nature of the new pathway had become clearer. Called CECS (Community Elderly Care Service), it was similar to the normal ICT service except that it was for over 75 years olds. The aim was not only to get early discharge of elderly patients from hospital but to do more to prevent unnecessary admissions to hospital. As a consequence, the front-end referral process would have to be more streamlined. Another aim was to take a larger number of patients and to move them through the intensive care process as quickly as possible. CECS would use SystmOne as its electronic e-health system and it would need to generate reports to inform progress on kpis. It was planned that a ‘virtual ward’ would be established in SystmOne: a list of all the patients currently on the pathway with up-to-the minute accounts of their condition and the care they were receiving. Such information, if available to all the team

members looking after a patient, would be the equivalent of the SAP information held on paper records at the patient’s home.

The clinical change facilitator said that, knowing these changes were afoot, there seemed no point in pressing on with the tidying up exercise because there would be requests for major changes in SystmOne in the pipeline. She said that IM&T were not involved in putting together the business case for CECS and that, although there were obviously implications for computer support, they still did not know what they were.

However, there was a meeting planned for the CECS project manager to brief them on what was needed.

8.2.6 Discussion

Although this case began as a study of e-health systems serving the ICT pathway it became a study of e-health systems to support a new pathway to provide community care for the elderly. In Walsall the ‘shared health and social care’ case was also of an ICT involved in the development of a Frail Elderly Pathway but Walsall had already implemented what Northamptonshire were planning. Since the two cases involve a similar ambition, the evidence from two cases will be considered after the Walsall case has been described.