Title: Author: Independent IM&T Strategic Review and Sample Service Workings. Paul Jacka, Technical Specialist, NHS South of England

Transcription

1 Title: Independent IM&T Strategic Review and Sample Service Workings Author: Paul Jacka, Technical Specialist, NHS South of England Corporate Governance Page 1 of 8

2 Note from author I wish to thank all involved for their input, allowing me access to their work environment during busy hours and taking the time to give an open and honest account of their situation and concerns. Without all their input this report would not be possible let alone enable potential solutions and recommendations. Detailed findings During the review it has become clear there is currently a disjointed working relationship between the Senior Executive Board level, Senior Clinical Department workforce, IM&T and how their activities align to the business strategies of the Trust. During the course of several hours of discussions with a selection of service senior staff members, IM&T and some Board members a picture emerged of commonly held concerns and perceptions about the current IT service which are technically possible to quickly, efficiently and cheaply resolve, with recognition to the required levels of communication skills and possible financial cost implications. The failings seem to be in several main areas none of which is personal or person-related. These in my view are: 1. Communication and leadership. There is very little, or in many areas no, communications between the service levels (clincians and General Managers) and the board / strategic level which has resulted in many good practices being lost or ignored. It has also led to a culture where requirements or strategies are not known to all parties and the organisation is not an informed customer. Some services feel they are over-looked when investment decisions are made and woukld like more involvement before any solution is purchased and is imposed on their department. 2. Accountability and responsibility. In my short time watching the working processes, reviewing policies, strategies, and what happens in the real world I quickly came to the conclusion that nobody feels able to act or take charge as they have not been granted the powers or abilities to do so. Though in many cases you have staff and departments who can do this and make vast improvements. This starts from the Board level and continues all the way down. 3. Customer services. The organisation feels that the service does not offer a high quality service which meets their needs in a timely fashion. This has been exacerbated by the influx of TCS staff who were used to a service, which they perceived to be more modern and responsive. 4. Perceived lack of confidence between many service departments not least Board, Clinical, Senior Management and IM&T. This confidence covers many aspects, including technical capacity and capability, past experiences, communication, delivery to time and budget and so on. 5. Perceived fear of costly solutions after many National IM&T projects spent urgently needed funds on white elephants which did not deliver the much hoped for investment. 6. Lack of joined-up thinking between service requirements, service users, clinicians, finance and departmental leaders. Corporate Governance Page 2 of 8

3 7. Severe inefficiency and time lost chasing paper. There is significant time being wasted when staff, unable to find records, unable to find data sources in a timely fashion to improve Patient care flows and pathways. 8. Out of date and unsupported, low funded, replacement systems in use that have gone well past their sell by date. These legacy systems are crucial to business and service objectives but their age means all service users suffer as the result. This includes multiple complex login and authentication to critical key services, resulting in users bypassing protocols to get the job done, thus potential placing the organisation open to risks. 9. Tender process too long in many cases. Detailed Recommendations 1. Communication and leadership of decisions When the CEO and/or Board make a decision it is to be published and mandated. That decision must be communicated to the relevant levels and departments swiftly, accurately and as one voice and not interpretations of. The best way to achieve this communication is with a clinical/business/im&t liaison function. This liaison will capture the Board s requirements, document, cascade the requirements through the service channels, ensuring those service channels accept responsibility to implement, monitor and report back on progress. The liaison will be able to communicate at all levels such as Chief Executive, clinical and non leads, whilst understanding organisational risk identification and scoring, financial constraints and technical service delivery. 2. Accountability and responsibility The Board quite correctly take full accountability for the Trust, however when remits, solutions and implementations are passed down the chain of command, so must the responsibility for implementation. Those departmental leaders must enforce the act, monitor and report back to the Board in a timely manner. This will allow the Board to concentrate on top level business solutions, only become involved a second time to step in if failing or accept the report of the departmental managers on progress, success or issues. On several occasions during my visits to NDDH, I have seen the correct procedures being circumvented for a manual written process purely because a user can. This freedom needs to cease and an edict of standardisation and requirement to use the Trust solution be imposed from Trust leaders to enforce the utilisation of solutions must happen very quickly. For example: White Boards. As discussed previously with Consultant A&E and Consultant Surgeon. The IM&T department has produced electronic versions that are tailored specifically for each departmental need with some very impressive designs and solutions ready to use, the issue is who will champion and enforce usage? If you did use this I am confident the Trust will improve in many areas very quickly for free; Multiple passwords to systems. This could result in users logging in and letting others use their login. Passwords can be written down next to devices as this is the only way the user seems to be able to work, however the organisation has purchased Corporate Governance Page 3 of 8

4 and invested great time and finances with Imprivata Single Sign solution that seamlessly integrates with PAS, Pathology, Radiology, PMS e-discharge, White Boards and GroupWise. This single sign on allows the user to enter one login to access multiple clinical systems quickly, efficiently and reduce security or IG risks. Adopting what IM&T has done in this area and I perceive your risks will reduce dramatically in weeks rather than months. Once again IM&T has no way to feed these solutions back into the correct organisational levels at present. Screen lock outs in 10 minutes. This is the standard set for the entire organisation. Please discuss with IG and consider the following solutions I have implemented in many NHS sites nationally: o Theatres and or Secure Clean Sterile operating rooms: change to 8 hours inactivity, as nobody should have to leave the operating table to move a mouse every 10 minutes to keep the view of a clinical record, X-ray etc. o Locked PA, typing pool rooms and secure consultation rooms between clinical staff and patient: change to 1 hour inactivity as some monitoring probes including gynae have a 30 to 40 minute cycle before readings. To ask a patient to go through such invasive procedures over and over again is not good practice. o All other locations remain at 10 minutes unless approved for change by IG and IM&T risk assessment. 3. Perceived lack of confidence I have used the wording perceived very carefully. To conduct this review I have spoken to lots of staff and teams both clinical (A&E, surgical) and non-clinical (IM&T). It has become apparent that there are solutions already designed, invested, paid for and ready for use to resolve many of the perceived areas of concerns. Unfortunately the implementation has been stagnant in many areas due to inability to get the solutions to the correct level of engagement and ensure they are utilised. There are two main aspects to this fear: A) Perceived fear of lost investment in an Electronic Patient Record (EPR) solution. The NHS s past history in delivering a system-wide EPR has not been great. We must learn from such disasters and ensure new ideas and solutions do not fail. There is no Golden Chalice, there is no single option that fits all requirements for IT healthcare. The successes have all been from smaller sections of healthcare implemented with clinical, technical and financial teamwork. The key is to only take on what you truly need in a prioritised order, affordably and resourced correctly to meet your service needs and interoperable with existing frameworks and future strategies and service designs. Some areas at the Trust work fine at the moment and should be lower down the prioritisation order. Others are in critical need of upgrading or replacement. Such service areas should be first to engage with. Recommendation 1 (Communication) with clinical involvement will provide known working solutions affordably and efficiently if funded and resourced. Then all services will gain faith and trust in each other and IM&T once more and all service users will benefit. B) Lack of joint strategies. Recommendations 1 and 2, and with clinical, financial, IM&T joint working will resolve this massive issue and gap identified. Corporate Governance Page 4 of 8

5 Over the short to medium term, it is recommended that you draft an over-arching strategy which sets out the projected plans and milestones for achievement over 0-6months, 6-12 months, months and months. These project plans need to contain time frames, resources and estimated costs so you can budget, plan and if required amend each section should service priorities change. All service solutions must be clinically lead and engaged from the project discussion to foundation work and onwards, plus have Key Performance Indicators (KPI s) for monitoring and reporting. C) Out of date Infrastructure and service delivery mechanics at present. This will be resolved in several areas, not least the IM&T time frames annex with costs and resources, so the entire service requirements can be mapped, placed into each category in a controlled and managed process thus creating greater efficiency and confidence with all services and service users, community and acute. D) Confirmation of OJEU minimal time has been extended as of January 1 st Legal limit is 65 days, best practice OJEU recommendation is 364 days! Buying Solutions Contract purchase can be as low as 90 days, however such short cutting can leave the organisation open to challenges and potential failed implementations. This timeframe creates the need for urgent planning and prioritisation of the service needs. Identified Potential Information Governance, Data Protection and Clinical Care risk 1. A&E Departmental Risk assessment: high, serious risk It is my judgement that the current system in A&E presents a real and high risk to patient safety. The system is almost entirely paper-based. As the patient arrives a CAZ card is manually created, printed sheets with patient details, multiple copies of records manually printed, written notes, left in reception who are flooded by service users 24*7. Though a policy of records tracing exists, often lack of time negates use, though it is a manual card and no historical data. Even if the receptionist is not asked, a record can be taken without signing and then a hunt begins for that record. Concerns by staff including Consultant A&E about the lack of the White Board with patient information of their location or treatment episode, no time tracks being used, as the use of was reported as a potential Information Governance (IG) risk. Risks: Financial loss of time, potential IG and Clinical risk, very inefficient working environment. My Recommendations: A) Utilise clinical override authority to show that the White Boards have a clear clinical and quality of care benefit, working with staff, IM&T and IG these can be placed and utilised to reduce IG risks as all other hospitals in the region do. Allow IM&T to show their work with electronic White Board systems as I have seen available to reduce patient wait times, duplication of works, track patients as they enter the department, leave for X-Ray, show tests ordered and discharge either home or to ward clearly and on track for 4 hour targets as interim solution. Corporate Governance Page 5 of 8

6 B) Utilise the smarter Single Sign-on Technology purchased, in pilot and with correct control and management/leadership available for departmental implementation. C) Investigate, with clinical input, electronic solutions to their service needs. Cost and prioritise the work within IBP and financial availability, whilst ensuring guidelines followed in this paper. Then procure and mandate its use to that service without exception. Consideration to prioritise actions in order for service to agree final order: 1. White Boards on wards, clinics, and other critical areas will be re-introduced with clinical advice, Information Governance advice to locate them, plus utilise the IM&T electronic White Board solutions urgently, within 2 weeks. These will be mandatory used by Senior Executives and Senior Management to ensure IG, efficiency and quality of care are enhanced in line with their design. 2. Board read, discuss and approve (if appropriate) the IM&T technical strategies without delay. 3. Board agrees to resource these solutions in full both in terms of capital and workforce. 4. Board will pass down the mandate of solutions to be utilised to departmental leads. Those departmental leads will have authority to implement, monitor and report back any updates, issues, but also successes. 5. Board will, in conjunction with finance, workforce leads and service delivery specialists, approve a job description for the Liaison post (Recommendation 1 Communication) and appoint as soon as possible following workforce employment guidelines. 6. The IM&T strategy is to move to NHS mail after verifying costs and usage, however some clinical leads should pilot the NHS Mail immediately to demonstrate its functionality and that it meets their needs. I would recommend the volunteer group to include those in this report, such as consultant A&E plus their immediate team/pa, consultant surgeon, PA and immediate communications team. This will test its feasibility, plus give more flexibility as NHS mail is available to ipad, iphone and other internet-facing services securely and will communicate very well with these staffpurchased devices. 7. Utilisation and deployment of the IM&T Imprivata Single Sign On solution tested to date. Start with pilots in those areas perceived to be under duress, then ensure medium clinical critical areas then service critical areas, thus ensuring a gradual build up of complexity and solution design for lowest impact and best efficiency gains possible. 8. It has been mentioned by a consultant surgeon that the A&E services has investigated with IM&T an EPR sub section for their use, these investigations should be rechecked, costed and gauged if suitable for service delivery and presented to finance and the board for approval as soon as possible. The only difficulty is Tenders/OJEU processes and costs in excess of Euros. Any such tenders may be delayed for a considerable time. A potential to use Buying Solutions, ASCC or other process will notify when this could be achieved and requires immediate verification and time frames for budgeting. 9. IM&T Strategies are aligned with service redesign plans, service needs and the IBP and utilise KPI s to monitor and report. As at the moment the IM&T plans are drafted but no joint planning process is available to ensure engagement and joint working. If the recommendations above are used as guidance or implemented then regardless of the IBP content IM&T will be able to meet the IBP content and be adequately resourced. Please ensure IBP and IM&T leads work in unison. Corporate Governance Page 6 of 8

7 10. IM&T to verify immediately how many devices are unable to run Windows 7, Office 2010 professional, and IE8. These will need to be costed of either upgrade, replace or VDI technology pilots to assure best value for money and budget casting, especially any year end about to be released. 11. Mobile care and technology. I was surprised to find the Trust have invested heavily in mobility, wireless and ward devices but very few are in use! This needs to be expanded with clinical leads and verify fit for purpose, which I am sure it is, then utilised to get value for money and savings as first planned. 12. Ensure in depth engagement at clinical level, IM&T and financial to start planning the EPR solution sections and prioritise as discussed earlier. In house skills are excellent in clinical, non clinical and IM&T. This a capacity, not capability issue and it is a fact that the team cannot do everything today/future in a short time frame. The Trust will need to invest in workforce and or contractual workforce if (as expected) we discover resources are too low to achieve the service needs. IM&T have great skills and need to be focusing on the strategy, which they can not do until one is approved. Future enhancements and strategy consideration: My own view as Technical Specialist is the following areas and time frames to be confirmed and costed: 1. Single Sign On 2. Follow a strategy to reduce manual input (paper-lite) with pre-filled fields and automated interoperability with other systems. (utilise drop down minimal menus, automated generation of discharge letters, electronic transmission to GP/Patient, colour coded monitoring with agreed escalation process, (green all ok, amber alert sent to agreed staff member/clinician as needing attention, red urgent action required or potential violation of legislation or potential impact to patient care)). 3. Review automatic screen lock outs 4. Use of video conferencing (clinical staff training, advice or consultation, reduce patient journeys to acute, thus community and even care at home could be done over such technologies, reducing travel, lost time and unplanned Acute visits.) 5. Move from Novell to Microsoft Active Directory (allow easier implementation of mobile technologies, IM&T solutions, group policies and best practice standards of IM&T, whilst still utilising the best parts of Novell to deliver complex environmental changes and service support such as; ZCM 11 patch and deployment technology, ZAM; Asset Management (if no other product matches but would recommend considering SNOW and Centrix) and a Pilot of ZAV for Virtualization.) 6. Upgrade where possible today to Office 2010, IE 8 and deploy 2003 compatibility pack for remaining Office 2003 devices until replacements can be confirmed as soon as possible. 7. Out of Hours, remote access confirmed for users and jointly led by clinicians and IM&T for testing and verification. 8. Standardisation across all services with clear mandates, support and strategies ensuring all sites and service users East/North are working in unison towards a better more efficient Care pathway, Service delivery and service Support. Finishing note from author: I could spend another week going through options and quick, potentially affordable wins for the organisation however this needs to be driven internally and approved by the board Corporate Governance Page 7 of 8

8 It is clear to me that key advanced skills are in-house, it is the depth and numbers of these resources that are potentially lacking, along with clear strategic focus. I would like to make it clear that I am accountable and responsible for this paper and content as this is my perceived and interpreted account, as such if any areas are inaccurate, wish to be questioned or just expanded please feel free to contact me post 28 th February 2012 when I am back in the country and I will attend and address all concerns. Paul Jacka (CISSP, #384489). 8 th February Technical Specialist Chief Technical Officer IT Security Specialist. NHS South of England South West House Taunton TA1 2PX. Corporate Governance Page 8 of 8