Powys Health Board Safety Closure Report

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1 Appendix 1 Powys Board Safety Closure Report Welsh Community Care Information System (WCCIS) Version 0.5 Jason Crowl RN.PGDip BSC(Hons) MSc Head of Nursing, project & Clinical Safety Officer

2 Contents Content Page Version 3 Approvals 3 Abbreviations and Acronyms 4 Related Documents 5 Executive Summary 7 System Definition/Overview 7 PTHB Pilot 7 Purpose of the Pilot 8 Pre-deployment Checklist 8 Outcome of the Pilot 9 Criteria Required for Deployment 10 Summary Report on and 14 Common Functionality Deployed in the WCCIS pilot Out-standing Issues to be 15 Resolved Prior to Implementation of Phase 2 Evaluation and Lessons Learned 17 Conclusion 22 Recommendation 22 Inserted Documents Deployment Sign off Checklist 8 Phase 2 Implementation Plan 9 Implementation Workbook 9 Phase 2 Gannt Chart 9 Regional Cab Process 9 Current Hazard Log 9 Client Information Leaflets 9 Duplicate Management Process 11 Version WCCIS Board Safety Case Closure Report Version 0.5 2

3 Version Update 0.1 DRAFT 0.2 Feedback from Pilot, lessons learned, roll out plan. 0.3 Final Draft 0.4 Revised Editing, Final Version 0.5 Revised 3/7/2017 to Reflect assurance level over Penetration Testing Results Approvals Version Name Role 0.5 Jason Crowl WCCIS and Clinical Safety Officer (CSO) 0.5 Andrew Gunney WCCIS Information Manager 0.5 Kara Price WCCIS Manager for Deployment 0.5 Caroline Pears WCCIS Strategic Programme Manager (Social Care ) and Integration and Technical Configuration (PCC & PtHB) 0.5 Ellen Sullivan WCCIS Strategic Programme Manager and Social Care 0.5 Programme Board Programme Board 0.5 Clinical Directors PTHB Clinical Directors 0.5 Information Management, Technology and Governance Committee PTHB Technology Governance Security Role 0.5 WIAB Informatics Assurance for all clinical systems used in NHS Wales Abbreviations and acronyms WCCIS Board Safety Case Closure Report Version 0.5 3

4 Abbreviation Care Director PCC PTHB CSO FOT FRA GP HSCIC SCCI MHRA NHS NPSA RBAC UAT ECR Description The CareWorks application PCC Powys Teaching Board Clinical Safety Officer First of type Full Rollout Approval General Practitioner and Social Care Information Centre (Incorporates former NHS Connecting for Clinical Safety Group) Information Standards Board Medicines and care Products Regulatory Agency. The MHRA is an executive agency of the Department of. National Service National Patient Safety Agency: Key functions and expertise now transferred to the NHS Commissioning Board Special Authority. Role Based Access Control User Acceptance Testing Electronic Client Record same as Electronic Patient Record Related Documents WCCIS Board Safety Case Closure Report Version 0.5 4

5 Reference Title 1 SCCI 0129 Informatics Application of clinical risk management to the manufacture of health software 2 SCCI 0160 Application of Patient Safety Risk Management to the Deployment and Use of Software 3 A Risk Matrix for Risk Managers (National Patient Safety Agency January 2008) 4 Risk Assessment made Easy (National Patient Safety Agency March 2007) 5 ISO/TS 25238:2007 informatics Classification of safety risks from health software. 6 CareWorks Patient Safety Assessment & Safety Case & Document ntryid45= ntryid45= etc./catalogue_detail.htm?csnumber= V2.0 WCCIS Board Safety Case Closure Report Version 0.5 5

6 Hazard Log for v Powys UAT Evidence 8 CareWorks Release Notes v CareWorks Administrator Guides v CareWorks User Guidance v SCCI 0160 Compliance Matrix 12. NWIS Hazard Log 13 CareWorks Clinical Safety Patch Report for V1.0 V1.0 V1.0 V1.0 V 1.0 V1.0 Executive Summary As part of the WCCIS solution Powys Teaching Board (PTHB) and Powys County Council (PCC) have deployed v of Care Director as a WCCIS Board Safety Case Closure Report Version 0.5 6

7 single integrated region into an agreed pilot site within Powys PTHB. The pilot was conducted over a 30 day period from 24 th April to the 30 th May 2017 and was deemed a success. No safety incidents were raised during this pilot. This safety closure report has been written to ensure that the NHS England Safety Standard SCCI 0160 has been followed by the Implementation Team to provide clinical assurance in relation to the implementation of the integrated client records system. PCC transferred from their current system to WCCIS and using functionality already developed and in use by Bridgend and Ceredigion Local Authorities and has been agreed subject to a previous deployment Safety Case. This has also been recently implemented in Blaneau Gwent County Council. PTHB implemented a first of type functionality in a controlled pilot which was closely monitored over a 30-day period in conjunction with CareWorks. The above documents have been used when authoring the accompanying clinical safety case. No Safety incidents were raised by the Clinical Safety Officer during the pilot of the system. Based on the successful pilot the recommendation is that the CareDirector solution is rolled out to all users within the PTHB Primary and Community Care Directorate utilising a phased implementation plan. System Definition / Overview Care Director is a health and social care system built on the Microsoft Dynamics Customer Relationship Management (CRM) platform and will be used by PTHB and PCC as the case management application for its adult and children s social care case management activity. The PTHB Pilot Four PTHB teams joined the pilot and have confirmed that the functionality is working as designed and no clinical safety incidents were reported. Newtown Community Mental Team Llandrindod District Nursing Team Llandrindod Occupational Therapist Team Builth Wells Visiting Team PCC migrated their entire service from the Draig System to WCCIS. WCCIS Board Safety Case Closure Report Version 0.5 7

8 Purpose of the Pilot Before PTHB can roll out the system an initial discrete pilot was used to test the following areas: Security model works for Adults, Children s, mental and Integrated Services. Referral set up works for real cases Forms allow efficient and safe recording in real cases Reference data is correct for real cases Information sharing arrangements work for real cases Training was adequate to provide staff with necessary skills Revised Business Processes are correct Team culture Lessons learned from role out Information outputs Pre deployment checklist (PTHB) Deployment Sign off Sheet 1.1.docx Deployment Sign off Sheets were completed 1 week prior to deployment following a 3 week period of pre deployment checks. Previously to this all staff would have completed their Fundamentals Training Pre deployment checks aim to confirm that all staff are correctly placed within the correct team structure with the correct security settings. The team need to demonstrate they can complete the fundamental tasks, can navigate the system, have recognised the associated risks and have the right infrastructure and connectivity. The sign off is a three stage process. Stage 1 Release configured version to test connectivity, system and forms. Stage 2 Meeting with National, Professional Line Manager and team Manager with WCCIS Team to walk through the processes described in the Deployment Sign Off Sheet. WCCIS Board Safety Case Closure Report Version 0.5 8

9 Stage 3-1 Week Prior to deployment, final confirmation by of completed sign off sheet and agreement to implement to pilot astage. Outcome of the PTHB Pilot The outcome of the pilot has been deemed a success and considering lessons learned then the recommendation is that the CareDirector solution should be rolled out subject to an agreed internal roll out project plan. This should also include the upgraded version of The proposed phase 2 of the roll out is attached. WCCIS Powys Board Workstream Re Utilising a dedicated implementation workbook. WCCIS Implementation Work Gannt Chart Phase 2 roll out.xlsx Regional Change Management Process Powys Region CAB Process.docx Current WCCIS Hazard Log WCCIS Hazard Log JUne 2017 V8.xlsx Client Information leaflets to be deployed with roll out. WCCIS CY.pdf WCCIS.pdf Criteria Required For Deployment Welsh Informatics Assurance Board Deployment Caveats Have the professional staff who will be using the application in this pilot phase been fully appraised of the outstanding clinical risks associated with the functionality? WCCIS Board Safety Case Closure Report Version 0.5 9

10 There are four teams who were part of the PTHB pilot each team must meet a minimum criteria for inclusion in the pilot. This includes demonstrating an awareness of the different risks associated with electronic records. These are included in the fundamentals training and are covered in the Hazard Log (Number 1001) and will be provided to all staff as part of roll out. Outputs from an internal hazard workshop had already been incorporated into the hazard log and there were no safety incidents raised as part of the pilot therefore the recommendation is that the system is rolled out within the organisation. Have the professional staff who will be using the application in this pilot phase raised any concerns regarding the clinical safety of the system which have not been addressed to their satisfaction? There has been 21 separate road shows to over 200 health and social care staff which demonstrated the look and feel of the system and its core functionality. The has also undertake a full one day clinical risk workshop with Clinical Risk Managers, The Supplier and clinical representatives from the principle disciplines involved in the Pilot. There has also been regular presentations at Executive Directors, Professional Heads, Clinical Forums, Locality Management and Powys Safeguarding Meetings. In addition there have been 4 National skype demonstrations of the WCCIS to information system experts. The team has received significant feedback regarding a range of concerns and identified issues which have been added to the Hazard Log. This feedback has directed the configuration of the product, infrastructure and connectivity arrangements to resolve the issues and reduce risks where possible. The feedback from the pilot teams has not identified any new areas of risk or areas of risk that have not already been managed or resolved. Based on the feedback from the pilot teams and also the existing county councils who are using the same functionality there appears no clinical risks or general risks that would prevent future roll out of the system. Has a local risk assessment been undertaken on the running of duel processes i.e. limited electronic processes in WCCIS and the continuation of paper records? This risk has been identified during the workshops and the clinical safety workshop and has been more clearly identified in the Hazards Log (Number 1046). It is important to note that several staff groups are using multiple systems for recording client information currently and the implementation of WCCIS will reduce the number of overall systems in use. Each team who will use WCCIS are required to have access to a WCCIS Board Safety Case Closure Report Version

11 scanner to ensure paper records can be attached to the Primary Electronic Client Record in WCCIS. The pilot did not raise any new concerns relating to issues associated with working with multiple systems. It is anticipated that multiple systems will be a feature of the organisation and will not prevent the roll out of the system. Are there robust mechanisms in place for the management of duplicate records (the ability of the system to alert to duplicate records was explained, members required reassurance on the manual process in place)? There is a National Workstream which will inform the Powys Region on the final procedures which are to be applied. Until this is ready a local procedure has been developed to identify duplicates caused by PTHB and PCC data merging. As PTHB are not migrating any clinical information there primary record is the PCC record. When a duplicate is identified the NHS number is transferred to the PCC primary record. This then becomes the agreed record on the system. The Powys Region and currently review proposals submitted by existing users who will also have a comprehensive primary record alongside that of PCC. However, going forwards as other organisations migrate data into the live system there is a potential for significant numbers of duplicate records until a Nationally Agreed procedures are adopted. A procedure has been developed for both PCC and PTHB on how to manage duplicates within the system. This is placed second on the list of guidelines on the WCCIS intranet page which is accessible to all staff. WCCIS Managing Duplicate Records V2. Confirmation that the outstanding high clinical risks identified during the national risk assessment process have been formally accepted by the health board (as they either have local mitigation or it is outside of scope at this current time)? ALL Risks (Hazards) formally accepted by Powys Region have been carried through onto the Hazard Log as these are relevant to the Implementation. The Hazard Log has been agreed for the Powys Region only and reflects the local assurance arrangements. This is listed as part of the ongoing risk management processes of the system and will be continually managed as part of roll out. There are no identified High clinical risks within the hazard log as these have already WCCIS Board Safety Case Closure Report Version

12 been mitigated nor has any safety incidents been raised by any clinical staff using the system. Confirmation of the local approval of security model associated with viewing the patient / client record across the boundaries and specialities e.g. health and mental health. Hazard Log 1045 and APPENDIX 10 The local security model has been tested and meets the requirements set out by the professional leads and managers who will be responsible for the services undertaking the full deployment in PCC and the pilot in PTHB. The security model is imbedded in appendix 10 of the clinical safety case and referred to in the Hazard Log (Number 1045). The local security model is expected to change further due to final testing and also we expect it will be refined following the pilot. The security model has required minor amendments during the pilot and will form part of the standard configuration for roll out. There has been no issues raised therefore this is seen as being well mitigated. Do the Executive Directors professionally accountable for clinical services have any concerns regarding the clinical safety of this pilot scheme? To date As part of the sign off arrangements the PTHB Clinical Directors, relevant Professional Heads of Services, Locality Managers and immediate Service / Team Managers are all expected to contribute to the decision to include or exclude a service for the pilot. The full Safety Case and imbedded documents is available to all staff via the WCCIS intranet page. The Assurance model for the PCC and PTHB deployment has been taken to Executives of PCC and is planned was reviewed at PTHB Executive Directors meeting on the 11 th April. It is important to note that the pilot has been designed to reflect the various needs of different professional groups, the cohort of users is small enough for professional heads to oversee quality and governance and has been geographically located to be close to the base of the WCCIS team. In addition to the Careworks support the PTHB Pilot teams were supported prior to implementation and with additional focus following implementation by the / Clinical Safety Officer and the PTHB Information management specialist who has configured the team settings and from the WCCIS Applications Team. This included level 1 and 2 helpdesk support and Data Quality Clerks who were available to attend sites. The pilot confirmed that the processes in place were working well and no safety incidents have been raised. Therefore the WCCIS Board Safety Case Closure Report Version

13 recommendation is that the system is fully rolled out to reduce current organisational risk. Summary Report on and Common Functionality Deployed in the WCCIS Pilot. Functionality PTHB Requirement Test Period Test Requirement Assurance Result Login On Login On settings for users to work Test Manager WCCIS Board Safety Case Closure Report Version

14 Find Patient Create a patient Make a referral Client Summary Record Functionality Documenting an allergy Documenting an alert Documenting paper records Completing activities Mental Measure (For MH Services) Mental Act (For MH Services) Using Forms Discharge a patient Security Search to a known patient Create new patients Refer the patients to the team. Refer patient to other services / teams Locate and use client summary record Locate and use Allergies, Disabilities, Alert health functionality Create allergies for patients Create alerts for patients Complete the Forms reference section for patients Complete case notes for multiple appointments. Complete phone contacts for multiple events. Test MHM on patient Test MHA documentation for patients Locate a test form to use Complete a set for Save and edit a test form Clone a test form Complete a test form Discharge patients Test Security Groups to determine what can be seen by Not used in the live. MH Assessment Form did not function during the pilot and MHM workflow was not tested during the pilot. Not Pending Pending WCCIS Board Safety Case Closure Report Version

15 Attaching Documents Completing Consent for sharing users in different business units Attach documents. Referral forms, work and PDF documents Complete new consent for sharing on patients. Complete restriction of consent for sharing on a selection of patients. Complete a withdrawal of consent of a patient. Outstanding Issues to be Resolved Prior to Implementation of Phase 2. The Penetration Test undertaken in April 2017 identified several vulnerabilities to cyber security. Remedial action has not yet been completed by the supplier. WIAB will need to provide assurance that the system is safe for Board staff to use and does not expose the organisation to unnecessary risk. The pilot has identified that many clinical forms used by staff will need to be modified or redeveloped. Roll out will include the transition staff who were previous Draig users who are currently using the functionality deployed in the Local Authority Configuration Professional leads will be required to confirm the services which can progress from pilot to implementation based on configuration and forms. The audit of the search and reporting functionality is currently not available in the current version. It is not expected to be available until an autumn release of a new software upgrade. The organisation will need to confirm if roll out can proceed with the current version. The mobile version of the software has not been available for the pilot and is required for some services as part of their deployment. This is not expected to be ready until the autumn at the earliest but may be as late as spring Professional s and Service Managers will need to confirm if roll out can proceed without the mobile version. There are known gaps in functionality around the health specific elements, for example the management of clinics and inpatients bed management. There are no clear timescales for the release of WCCIS Board Safety Case Closure Report Version

16 the functionality. The organisation will need to confirm if roll out can continue without the absence health functionality. Evaluation and Lessons learned Area Feedback Action Learning Business No Action Processes Referral configuration as developed worked for the teams. Ownership which is set at the national level has not been agreed and is visible. This appears untidy to practitioners and they may select the incorrect reference data National reference data needs to be cleaned up. There are common referral configuration possibilities which can be applied across different teams / services Security As a regional team the security model has been developed, addressed and modified at a regional level. The security model has been tested. Planning to roll out new security roles Testing of the security model in a live before progressing to a more WCCIS Board Safety Case Closure Report Version

17 Information Sharing Forms During initial Go Live the security model was adapted and developed based on the feedback from the Floor Walkers and successfully tested. Model showed adaptability and quick to modify to suit integration needs. Currently clinical record information is not shared between health and social care in the Pilot teams. But there is information sharing between previously integrated / collocated staff. Basic demographic information is shared and the National client summary dashboard will show referrals between organisation s. Staff cannot update the demographic if the record is owned by a different organisation. The use of the access to additional demographic is necessary more frequently than intended due to the need to access the legacy ID. This is creating an unnecessary significant IG reporting requirement which demands evidence for reasons for accessing the additional demographic section Forms need some slight changes. Key element is the current way the forms are configured are less efficient. Single Point of Entry elements not working completely Forms have been implemented at a regional level, eg DOLS, OT, IDS and MARF Mental Form failed on launched and teams reverted to local forms and processes. to deliver more comprehensive information sharing. Awaiting final confirmation that the existing security models are working before information sharing can be switched on. Need to agree revision to the way the Additional Access section is used and the data fields behind it. Suggested that forms are revised to improve the efficiency for the practitioners, eg. Using entities, more skip logic and write backs. Need to look at forms on how they flow and lead the practitioner. SPE needs to be reviewed and checked by Form Builder Team Forms pick list need to be reviewed. complex security arrangements is recommended to manage the IG risk and control changes to the system Teams expect to share information. Teams are experiencing difficulties in delivering their duties when they cannot share information Powys has created records owned by the region which enables staff to change demographic data. Form building is more accurate when they are completed between a currently practicing practitioner and the form builder. Forms need to be tested in a live to determine if they work. Pre testing outside a live will not provide sufficient testing of the operational use and meets corporate WCCIS Board Safety Case Closure Report Version

18 Entities Training Equipment Workplace Dashboard Staff have used a limited number of the entities, namely consent and disabilities and relationships. A common training on fundamentals was sufficient for the basic use of the system. A need for service specific training was recommended for some services or roles (eg managers) where the use of the system is specialised of distinct. Staff experienced a range of equipment failures with netbooks and were impacted by National Cyber attack. Dashboards do not show the type of caseload criteria and how the data is broken down for the system Teams will be progressing to report allergies and risks. Training Coordinator to work with the teams over refining the training. Improve pre testing of equipment on during pre check stage Team to work with the practitioners to develop a dashboard to meet requirements against legislation. There is a conversation to be had at the national and regional level regarding how entities are used in the system to create a common sharing of information around Risks, allergies, abilities etc. This is impacted by agreement of National reference data and professional behaviours and recording practices. Staff need to be encouraged to use the training guides, the procedure guides and to access the on line training videos. Managers and Professional leads need dedicated support and training to use the system. Ensure teams have robust contingency plans. Test equipment prior to go live. Change suppler of the netbooks used for the project. Initially staff did not use the workplace dashboards. These became more relevant and valuable to the team as the activity in the system increased. Due to the way dashboards are built there is the potential for a workload associated with managing dashboard views. WCCIS Board Safety Case Closure Report Version

19 Patient Dashboard Network Software Human Support Revised version submitted Staff login issues were created by incorrect settings in the AD accounts. Issues reported with MS Edge and Internet Explorer versions and Chrome. These impact the way the product work. DQC support has come to some of the teams later in the pilot and would like them to be part of the service roll out from the start. Where DQC support was deployed pre implementation and during the first two weeks the team adopted the system quickly. Staff with configuration knowledge were able to make changes quickly. Having staff with a range of skills walking the floor was effective in the initial roll out phase. Having management and leadership visible during roll out was effective in allowing for quick decision making and provided assurance to staff. Having a clear communication strategy and clear messages to staff was effective. The coordination back at base of the support staff during roll out enable support staff to be targeted to problem areas Revised dashboard to be resolved Ensure all AD accounts are checked during the pre live check. Ensure systems are checked before deployment and staff aware of the issues. Team to engage with the Work Stream s regarding their presence during future roll out National Dashboard was not used. Local configured dashboard was used and further amendments for the dashboard has been suggested. It is expected that there will be several client dashboard views. Complete checks on the AD account prior to deployment. Test all devices to ensure access to the correct software is available. Ensure profile settings enable updates to the software. Ensure staff have access to the correct guides re the software interactions. Face to face trained support is critical for a successful go live. Based on the number of support visits and the nature of the visits it is anticipated that a team will need extensive support in the first working week of a roll out which is then tapered off over the subsequent weeks. This needs to be built into future roll out plans. Ensure staff know who is walking the floor and have access to contact details. WCCIS Board Safety Case Closure Report Version

20 Key staff Messages Migration staff confidence needs building as staff are perceiving they are documenting in the same way as paper. staff reporting the system is longer to use in comparison to paper. Transition from Draig to WCCIS was not a significant transition on Go Live. Data migration was not mapped by the Supplier, this caused additional work in the team to follow up on the migrated data to confirm where this impacted on current business processes. staff identified that the inputting of data is best undertaken by admin and clinical staff together who are from the actual team. This encourages learning and ensures safe practice. In Visiting, due to the need to have a referral on the child and the relevant adult (s) on the system there is a potential caseload number of 1000 per Visitor. Reference data and where it is set within the system needs to be formally agreed in a timely manner. Management teams in are starting to identify impacts to how the services are delivered. Teams report high level of duplicates in the system. There are cross authority duplicates between LA and and due to health migration of Need to review the business process works to determine if there are alternatives to developing large caseloads. The responsibility for a de-duplication for organisations processes needs to Business service transformation is the hard part of the project. The system itself is essentially the easier element. The teams which had clear leadership in at least 2 or more members were able to take the whole team forwards and required less support. Teams which had clearly identified Senior Managers who were actively engaged in the deployment and interfacing with the teams were quicker to adopt new ways of working. Services which have identified the implementation of the ECR via WCCIS as essential to the delivery of their strategic objectives appeared to better align support resources essential to a successful deployment. The system will challenge the current health working practices which had previously been designed and agreed with a paper based approach. It is evident that the Local Authority which has over 10 years experience has overcome and managed these challenges. Organisations need to confirm their migration requirements, their local, regional and WCCIS Board Safety Case Closure Report Version

21 demographics there is a large number of regional duplicates. be agreed before migration. national de duplication processes. Help Desk Support and Device Management The feedback showed the capacity of the helpdesk and device management support was overwhelmed and unable to deliver a timely response. In part this is due to the impact of the National cyber attack requiring devices to be removed from network access and staff to be re allocated to restoration issues. The Supplier needs to move the legacy ID field from the Additional Information Section as this is used in identification of duplicate records. A review of the SLA of the help desk is required to ensure the service side has the necessary responsive support. Organisations need to implement learning from organisations which have a long history of managing electronic client records. Establish a prioritisation structure for replacing equipment. Ensure the support functions are adequately supported. Conclusion The implementation and pilot have been successfully completed, providing valuable information of the practitioners experience of using the system and key lessons required for planning the further roll out. No new concerns were raised that had not been anticipated. No clinical safety incidents have been reported during the pilot. The general consensus is that the system itself is straight forward and safe to use. The primary challenge experienced by the practitioners is the transformation of the organisation in which the system will operate. The pilot demonstrated that there needs to be continued and extensive work to meet the transformation agenda associated with a phased roll out. WCCIS Board Safety Case Closure Report Version

22 The pilot tested the common functionality which is used by both health and social care. PTHB tested the functionality which is currently used safely and effectively within three local authorities and found that it could be used effectively for health care practitioners. Recommendation 1. PTHB confirm with WIAB that outstanding issues regarding Penetration testing have been resolved or mitigated and that WIAB recommend the system for deployment for NHS staff working in Powys. 2. Based on the feedback and lessons learned from the pilot it is recommended that PTHB consider to move to the phased implementation of WCCIS in services with the agreement of Professional leads and Line Management and the Programme Board. 3. The roll out would utilise the common functionality used by both PCC and PTHB within the Powys Region as used during the pilot. 4. PTHB move to consider a business as usual position in respect to the roll out, continued use and continued development of the local and national aspects of the system. 5. The Hazard log has been reviewed and no changes have been made as the pilot is deemed as a success and the mitigations in place ensure there are no High or Medium clinical risks. WCCIS Board Safety Case Closure Report Version

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