Organisation Details Please complete the table below, providing details for the organisation with lead responsibility for the project. Remember that the applicant must be an eligible organisation as defined in the Prospectus. Organisation name: Address: Barts Health NHS Trust Executive offices, Ground floor, Pathology and Pharmacy Building, The Royal London Hospital, 80 Newark Street, London E1 2ES ODS organisation R1H code: Key contact Luke Readman name: Key contact role: Chief Information Officer Key contact e- mail address: Key contact phone number: Luke.readman@bartshealth.nhs.uk 020 3 246 0641 Project Key Details Please complete the table below, providing key details for your proposed project. Remember that the Prospectus sets out a number of criteria for a successful application. Project title: Paperless Nurse Observations Solution devices: Solution software: Solution practitioners: Financials funds requested: Financials return projected: Plan spend date: Plan go-live date: Cerner Welch Allyn Connex Vital Signs portable monitoring devices Cerner Millennium CareAware Ward based Nurses and midwives 935,006 5.24 Funding will be spent by 31 st March 2014 Pilot go-live date 1 st March 2014 (three wards), devices installed on all wards by 31 st March 2014 with functionality rollout planned from 1 st April 2014 through to 30 th June 2014. Project priority: This Project has Priority 1 Other partner organisations: None
Project Aim and Description This project enables nurses and midwives at Newham Hospital to capture vital signs observations at the bedside in real time. The solution is based on Cerner CareAware VitalsLinks, which connects mobile vital sign monitors directly to the Electronic Health Record (EHR) enabling the patients vital signs data to flow directly into the patient record. The focus for the bid is the purchase of the VitalsLinks monitoring devices (Welch Allyn Connex Vital Signs Monitoring devices as referenced on the technical diagram) coupled with the technical knowledge required to support their implementation. Currently vital signs are charted on paper. The nurse then uses a paper based tool to calculate the Patients Early Warning Score (EWS). The nurse is reliant on an alert from the Health Care Assistant if the vital signs are outside normal limits. This process is slow, dependent upon the nurse recognising deterioration in the patient and informing the clinician enabling prompt treatment. The paper information is not visible to others nurses or clinicians, which often results in delayed review by specialist teams and ultimately discharge The Barts Health Strategy of moving to a fully digitalised electronic health record (EHR) is based upon implementation of a suite of integrated clinical modules within Cerner Millennium. Once deployed these modules derive a single clinical system, which forms one part of a longitudinal patient record. The technology proposed will facilitate paperless observations enabling a patients vital signs and EWS to be available to all clinical staff in real time thus eliminating delay whilst effecting rapid intervention. This project is therefore integral to Strategy and development of the EHR. The project will deliver the following benefits: 377 Increase nurse efficiency by streamlining the vital signs process and saving time Improve patient safety as vital signs data and EWS will be available to all clinicians in real time, thus eliminating treatment delays The availability of real time data and increased efficiency leads to improved discharge planning and length of stay management Real time vital signs data leads to improved care decisions reducing the risks of patient deterioration and the number of reportable clinical incidents. Significant time is released to reinvest in patient care which feeds back into the caring and compassionate focus of nursing care in line with the national nursing strategy, (2012). Strategic Alignment The Barts Health informatics strategy has three components: single system, connectedness and population health transformation using big data. This project aligns with all three components. It utilises the single system, ensures connectedness and
enriches the volume of data available to different parts of the health system. The project also aligns with the overarching aim of improving patient ownership of data and developing health self-reliance in the home. The Trust has deployed Cerner Millennium across most of its estate and has a clear roadmap for deploying additional functionality to support clinical care as well as ensuring that the whole Trust works from a single domain. There is now a mature team with deep understanding of the Cerner product and the capability to make data exchange with primary care and community systems a reality The nursing strategy is based upon safeguarding the six fundamental nursing values, which form an essential pillar of the wider informatics strategy. The nursing ethic is one of constant improvement through professional and individual motivation to provide the best possible care across all healthcare setting. Nursing and midwifery teams are striving to work with local care groups and patient forums to reduce hospitalisation using the data held in the EHR. New model processes are developing by combining data from the EHR with data from primary and community care. Our long-term vision is to create an EHR that moves away from the traditional costly paper based and inefficient models of care present and react, to more efficient and effective electronic models that focus on predict and prevent. This project is well aligned with the strategy. It enables nursing and midwifery professionals to concentrate on using one system, the EHR. The project also provides the mechanism for adopting use of digital mobile technologies to capture and share data in real-time, with, clinicians, wider nursing care teams and most importantly, the patient. Data captured at the point of care improves data quality and the value of that data for future information and analysis. Delivery of this project not only secures a significant step forward for nursing and midwifery care but it also demonstrates the value of an integrated electronic health record. 360 Digital Paperless Roadmap The Trust s informatics strategy is to make services and data more accessible whilst improving quality and reducing cost. Digitisation of healthcare data is central to facilitating data sharing. Shifting the care process reinforces the value of a digitalised electronic health record (EHR) that is predicated on implementation of a distinct set of integrated clinical modules. Once deployed these modules derive a single clinical system, which forms one part of the longitudinal patient record. Modern Healthcare requires effective, real time links across care systems. By providing access to digital patient information across multiple health services, without requiring new systems, the Trust can move away from data silos to connected healthcare enabling a richer, more complete view of the patient.
The move to paperless is well advanced. Some departments have made advances towards a paperless environment; these include the Emergency Department and Pathology. The transition to paperless vital signs recording provides the next step along the EHR journey. The roadmap, building on existing functionality, is presented below. 1. Establish the pilot at Newham utilising value gained from the recent code upgrade to 2012 code base. The pilot to be set-up by 1 st March 2014. 2. Evaluate the outcomes from the pilot during April 2014. 3. Apply process amendments as required prior to implementing the full rollout to all wards. Rollout to be complete by end of June 2014. 4. Rollout will be phased to ensure adequate time is allowed for the implementation of workflow changes and to ensure training is completed; Funding will advance and streamline the delivery of goals 1 to 4, enabling work to start earlier. It will also enable earlier engagement with nursing and medical teams ensuring that support is fully assured. Ultimately funding will ensure that benefits can be realised earlier. 293 Nursing Leadership The project will be led by an Informatics Clinical Engagement lead who is a senior nurse. This will ensure that the enhancement in technology will be viewed as the implementation of solutions, not problems, and will be appreciated by nurses as adopting improvement in meeting practice needs and enhancing patient and staff experience. The senior nurse will fully engage nurse colleagues and others to adopt the solution and provide operational direction at ward level. This person will present findings and progress to project board meetings and integrate the strategy with the operational delivery. The project board will have strong nursing leadership ensuring governance through the appointment of the Associate Chief Nurse (Informatics), as the Senior Responsible Officer. Directors of Nursing of each Clinical Academic Group have already been involved in decision making through the Nursing Informatics Steering Group. This project has been approved by Professor Kay Riley, Chief Nurse of Barts Health and lead of Corporate Nursing and Governance. The Nursing and Governance team includes quality and governance, patient experience, care standards, safeguarding, and nursing informatics and innovation. Therefore there is a strong and senior nursing presence which will underpin the leadership and ownership of this development which will feed into the emerging paperless strategy. 205 Sign-Off Process This project is incorporated in the Electronic Health Record Full Business Case. The FBC has already been approved by the Trust Executive Committee and is due to be presented at the Trust Board in January 2014 for sign-off. The FBC includes the capital cost for the implementation of the Cerner Millennium Phase 4 Programme of which
CareAware is part, detailed analysis of the on-going revenue consequences and a comprehensive benefits realisation programme. Capital funding to support the EHR strategy has been approved for the next three years. 87 Technology Diagram Applicants are asked to submit a technology diagram that clearly shows the following; 1. The technology for which funding is requested 2. How the technology will integrate with existing systems and technology 3. Any changes, upgrades or additions to existing infrastructure that are required for the new technology The diagram must be submitted as a separate file as detailed in the Application Instructions for Bidders document.
Realising Benefits The BMJ Quality and Safety report (2012) highlights that one in twenty deaths in hospital is preventable. The vast majority of preventable deaths result in part from inadequate clinical monitoring. The Resuscitation Council in 2010 stated that early warning indicators could alert nursing staff to initiate prompt and effective clinical monitoring processes. Automated electronic early warning systems facilitate the introduction of early intervention processes, which ultimately saves lives and improving patient safety. Furthermore, transcription errors from manual systems are eliminated. Significant time delay results from the manual recording of vital signs and subsequent recording in the electronic format. Moving to a paperless solution enables clinicians to gain access to accurate up-to-date patient information in real time thus improving efficiency and resulting in decisive care decisions. Efficiency time saving will be gained for both nursing and medical staff. Patients discharged from ITU to general wards are often at risk in areas where nurses are pressured and lack the critical care skills to identify a deteriorating patient. CareAware enables critically ill patients to be identified and automatically calculates the EWS score. This information is visible to the critical care outreach teams who can respond and treat the patient proactively. Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Quality and Safety, published online July 7, 2012 231 Project Context This project forms an integral part of the Trust s informatics strategy as it builds upon existing initiatives all of which are designed to support the transition towards paperless processes. The strategy establishes a detailed roadmap for development of the EHR over the next five years. The EHR programme is divided into a number of phases covering all sites, staff groups and community health partners including most importantly patient groups. The size and complexity of Barts Health uniquely provides it with opportunities of introducing new ways of working into discrete areas of the organisation. These test areas allow functionality to be evaluated in pilot form before implementation on a wider scale. These pilot evaluations form fundamental strands in the development of the EHR. This pilot and rollout constitutes one such strand. The Roadmap comprises the following phases: 1. Building on the recent hardware and software upgrade at Newham through the
introduction of new functionality. Implementation of CareAware, the basis of this bid is included in this phase. 2. Complete the transition of Whipps Cross to Cerner Millennium by March 2014. 3. Complete the implementation and rollout of the new Trust-wide RIS and PACS solution by autumn 2014. 4. Commence the design and build for the introduction of additional functionality at the Royal London. This functionality includes the central building block for medicines management, critical care, anaesthesia, bedside device integration and pathology. 5. Transition away from the BT datacentre to an alternative datacentre the detail of which has yet to be finalised. 6. Upgrade the code base at Royal London and Whipps Cross and integrate with Newham to form a single Barts Health electronic health record by winter 2015. The Business Case for the Roadmap has already been agreed by the Trust Board and funding is allocated to future years. Funding from the Nurse Technology Fund will enable CareAware to be rolled out much faster across Newham ensuring that benefits will be delivered sooner as will lessons learnt that would be carried forward into the wider implementation of CareAware at the Royal London. Due to other technological enhancements taking place at Newham staff are already engaged and enthusiastic about introducing new Cerner functionality, which will complement existing improvements being made e.g. in Older People Services. 373 Project Delivery Approach The implementation approach will be to pilot the use of the national observation chart utilising CareAware on a small number of wards at Newham to design and build the best workflow, test the stability of the technology and determine the EWS algorithm. The aim is to complete this by April 2014 and then rollout the solution to all wards. The Informatics Clinical Systems Team will lead the project and subsequent rollout. The Clinical Engagement Lead (senior nurse) will act as project manager to ensure that the project satisfies the requirements for nursing process change and supporting nurses and midwives to adopt the associated improvements in nursing practice. The Associate Chief Nurse (Informatics) will act as SRO for the project thus mandating that clinical awareness and engagement are assured. This will ensure that the project is viewed as nursing clinical change and not a technology project. The SRO will present findings and progress to Trust Executive meetings, whilst the nurse project manager will integrate the project with the operational delivery. Where strong clinical engagement is attained, benefits will be delivered more consistently. Ensuring clinicians are committed and supportive of using new technology is easily achieved, provided they are fully involved and understand the workflow changes required to achieve the benefits identified.
Hands-on clinical leadership and direction during periods of change are essential components of a successful electronic solution; it has been shown that excluding clinicians from the planning and only involving them at implementation will greatly reduce the usefulness of the technology and limit the benefits to be gained. (DoH 2013). Key milestones: 1. Sign-off pilot scope by 31 st January 2014 2. Delivery of VitalsLinks devices from Cerner by mid-february 2014 3. Install all devices by 31 st March 2014 4. Test and sign-off of VitalsLinks device installation in pilot areas by 28 th February 2014 5. Commence pilot 1 st March 2014 6. Review pilot and benefits plan 1 st April 2014 7. Commence rollout mid-april 2014 The vital signs project requires consistent project management, cohesive policies, informed guidance, well-defined processes and clear decision-making. The Informatics Committee encompasses these responsibilities. The Committee will: 400 Track and drive progress and maintain momentum Ensure there is integration between individual projects and the overarching Informatics Identify, escalate and manage risks, issues and dependencies Ensure necessary resources and funding are committed Identify resource spikes and any resourcing issues Communicate relevant issues to senior executive team and Trust executive team Clinical Change Approach Healthcare Information and Management Systems Society (HIMSS) defines clinical transformation as assessing and continually improving the way care is delivered at all levels in a caring organisation. It occurs when existing practice patterns are rejected that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and IT implementation The Trust emphasis for clinical transformation is to motivate and stimulate users to deliver benefits to clinicians and patients. The digital adoption programme focuses on improvements to clinical practice, increasing efficiency whilst stressing the importance of maintaining patient safety. High quality, safe, efficient care for patients is the key objective for Barts Health underpinned by aligning clinical change with improving the knowledge, skills and confidence of all staff. This project builds on the Patient at the centre of everything we do initiative. The clinical change approach is to map out the As is and the To be processes and
then re-design the workflows. A key aspect of this allows logging, capture and management of change. The clinical change approach therefore involves working collaboratively with multidisciplinary teams to map pathways and identify processes which will improve with the introduction of new clinical functionality. This will be achieved by involving stakeholders throughout the process of identifying the clinical need through to design, testing, training and implementation. The cornerstone of the strategy is to use the existing change management and quality improvement strategies utilised by the Care Quality Collaborative forum this has a strong focus on quality, reducing the incidence of the Four Harms, concentrating on patient safety and experience #Becausewecare; having a multi-disciplinary approach. Successful clinical change projects developed by the CQ include reducing the number of patients admitted to Critical Care with preventable deterioration from a trauma ward and reducing the incidence of falls on the Coronary Care Unit using Driver Diagrams, SMART approaches, Run Charts and the Plan Do Study Act cycle methodology. Accompanying formal training is the Buddy Programme. This provides the opportunity for future users to observe or Buddy with existing users; supporting knowledge exchange, workflow understanding and further adoption. In contrast the Champion User Programme has been developed to enhance the adoption of clinical systems. The Digital Adoption Team provides training, knowledge transfer and soft skills in communication, training and leadership to equip staff with the skills they require to support colleagues and patients. 398 Sourcing Strategy Following the merger with Newham, the Trust has a direct contract with Cerner for provision of Millennium services across multiple sites. This contract will form the basis for to the pilot and subsequent rollout, consequently there are no contractual barriers thus the pilot can start immediately. This project makes no fundamental change to the existing Newham contract as it concentrates upon extending the use of existing functionality. The Trust has participated in the London re-procurement project, which following OJUE has resulted in a framework agreement, which incorporates a catalogue of applications and services. Cerner will be providing the Welch Allyn Connex Vital Signs monitoring devices as part of the above contract. These devices are fully integrated with Cerner Millennium therefore requiring minimal configuration, installation is consequently straightforward. 127 Supplier Partner Capability Assessment The Trust, having worked for some years with Cerner, has built up an understanding of
their capability. Barts Health has a mature relationship with Cerner, which is based on partnership and developing a common understanding of organisational goals. Accountability for delivery the Trust s EHR objectives is managed on a shared basis. In addition the Trust has significant experience of deploying and testing vendor products and has recently implemented new Cerner functionality, which it has designed and tested locally, this had led to successful implementations. 84