Warning: this article has no news of groundbreaking work, big bangs, rocket science or cutting edge technology.
The Rotherham NHS Foundation Trust doesn’t do ‘revolutionary’ anymore and the mantra repeated by the team tasked with turning around its IT and information system is: “slow and safe”.
Don’t switch off, though, because The Rotherham’s ‘steady hands on the tiller’ believe they have some important experiences to share.
While their lessons learned and recounted below may be familiar to many EHI readers, executive director for health informatics, Dr Trisha Bain, says that in her experience many are skipped or ignored.
“It’s been a difficult journey and not one that we want to repeat, but I think it has benefitted us greatly in terms of knowing what we want to do and how we are going to do it,” she adds.
Bain moved from her role as head of the trust’s business intelligence services to take charge of the trust’s informatics 18 months ago.
Rotherham had committed to installing the Meditech v6.0 system, but had run into difficulties with the implementation – difficulties that were serious enough to attract the attention of foundation trust regulator, Monitor. A recovery plan was essential.
Richard Slater, the trust’s clinical informatics lead and a general surgeon at Rotherham General Hospital, headed up the efforts on re-engagement with the clinicians. He says colleagues had wanted the system to succeed but felt that the suggestions they made had been ignored.
So here, with no apologies for repeating what some may consider blindingly obvious, is some sage advice from Rotherham’s recovery team delivered as they begin to see light at the end of the tunnel.
Rotherham’s guide to ‘Slow and Safe’
Set up a project management office and resource it properly
Setting up a well-resourced project management office is an essential step in controlling a project and understanding the sequence in which developments have to happen if the overall project is to be successful, Bain emphasises.
A PMO is also vital to ensure that clinical and business priorities are recognised and understood and that ad hoc shifts of focus are resisted.
Don’t be over-ambitious
Bain’s professional background in systems and processes informs her view that a step-by-step approach, signed off at every stage is the safest, surest route.
Slater agrees; reflecting that, with hindsight, it would have been better to describe the initial work on the system as a patient administration system replacement rather than a whole new system. Every cliché about boiling oceans and eating elephants is true!
Don’t take short cuts, test everything
The Rotherham team tests out all changes rigorously. Even apparently obvious changes tend to throw up several issues, mostly easily resolved, but definitely in need of resolution before a new workflow, can be introduced more widely.
For example, orthopaedic surgeon, Kingsley Draviaraj, replaced paper notes delivered by nurses with electronic messages to tell orthopaedic technicians to remove casts from patients presenting in outpatients. It was a simple, time-saving move, but one that was tested by Draviaraj before being used by other surgeons.
This slow and safe approach has also been adopted in creating electronic operation notes for orthopaedic procedures based on templates drawn up by Draviaraj and tested before going into wider use. Gynaecology surgeons are keen to follow suit and are looking at adapting the same process to change their practice.
Create a health informatics function covering IT and information
IT and information belong together. Bain and her information team were among the first to see that the initial implementation was going wrong because they could not get the information they needed out of the system. This, in turn, had serious implications for the trust’s finances, governance arrangements and reporting.
Often, she believes, the emphasis in a project is too heavily weighted towards the technology. Consultants hired to do an implementation can be too closely focused on the technology rather than the information it should be producing.
Clinical engagement is essential
Re-engagement in the implementation was aided by a positive attitude from the clinical staff. A clinical lead was appointed in every specialty and they have all put time and effort into the recovery. This was a critical investment for The Rotherham; although it might look like a difficult decision for trust boards to make in the NHS’s current financial position.
The reward has been a clinical workforce that is beginning to understand how it can use the system to drive the changes staff want to see. Paperless clinics, electronic operation notes and e-prescribing have emerged as priorities.
Communication, communication, communication
“Email has been the death of communication,” Slater observes ruefully. The Rotherham team emphasise that personal communication is essential and that there is no substitute for getting around and speaking to people. Reliance on email should be avoided.
A network of super users, regular training and the dissemination of knowledge and experience form the basis for improved communication.
Don’t rely on contractors; build skills in-house
Bain suspects that many people involved in a large scale deployment underestimate the effect it will have. Her message is that it will impact on every element of the organisation and that contractors, however able, are no substitute for knowledgeable people on-site.