Leapfrog: how Global Digital Exemplar Blueprints can accelerate your transformation

What will success look like?

Blueprinting will share learning from the Global Digital Exemplar Programme

➢It will make it easier, quicker and cheaper to replicate innovations

➢It will demonstrate the value of technology and the impact on clinical care and operational delivery

Where we are and what next?• We have piloted the approach – our thanks to Cambridge, Royal Liverpool, Luton

and Dunstable and Birmingham

• We have prioritised our first blueprints - the GDEs and Fast Followers are starting to produce them to be ready in the Autumn

• The LHCRE programme will also produce blueprints and we are joining up on the approach

What are blueprints and how will NHS trusts benefit?

Gareth Thomas & Paul Charnley, co-chairs of the Blueprinting and Learning Network Steering Group

Before today what would you say your level of knowledge is about Global Digital Exemplar Blueprinting work? • Very good

• Good

• OK

• Poor

What do you expect to see in Blueprints? • A detailed story showing the journey through a particular digital transformation

• A set of technical specifications to implement digital improvements

• A series of supporting guides and documents to implement a digital project

• All of the above

• Something else

A quick overview – an animation

What is a Blueprint?

A blueprint IS:

• A record of a GDE/FF’s experience with digital innovation, centred on their key work activities and including lessons learned along the way.

• Supporting information and artefacts that provide project details, examples, and tools.

• A set of information that is searchable and filterable by different users, based on need.

• Live document that allows people to seek further information

A blueprint is NOT:

• A mandatory, ‘one-size-fits all’ guideline for every trust.

• A static collection of material that doesn’t evolve over time.

• Primarily a marketing instrument; rather, its purpose is to inspire, inform, and accelerate digital innovation in follower trusts through lessons learned (good and bad).

8

Rapid access to insight –

Blueprints will cover a range of dimensions and interests

Care setting

Care pathway

Digital capability

Board – Fully tech agnostic

CCIO / CIO – Mainly tech agnostic

Implementation and clinical frontline teams – tech specific

Story-like—a compelling narrative of actions and events:

• Stories are familiar and engaging, instruct without dictating

• Stories accommodate the adaptive component of change

Actionable:

• Discrete steps, milestones, and outputs

• Tools others can leverage

• Content presented according to the needs of different audiences

Balanced:

• Actual and ideal

• Theoretical and practical

• Generally applicable and site-specific

Our design principles

10

How a blueprint might look on a digital platform

11

Categorical information collected… Chronological story presented…

Benefits & Outcomes

Digital Capabilities, Infrastructure, Readiness

Type of project

• Key Decisions

• Key Learnings & Advice

• Artefacts

How we will collect and present Blueprint information?

• The GDEs and Fast Followers will produce a number of blueprints over a number of years – some will be joint.

• They will be assured by users for relevance, completeness and quality

• There is a methodology and framework for creating blueprints, with support materials such as design guides and collection templates.

• We will also look to provide some central support to the GDEs and Fast Followers

Who is producing the Blueprints and how?

Our early priorities

GDEand FF sites proposed their top 5 ideas, considering impact, outcomes and readiness

These have fed into a Blueprint portfolio

We are keen to hear more about what topics you would like covered?

Customer demand

Key stakeholders

and /influencers

National policy and

clinical priorities

Breakdown of Blueprint ideas submitted by sites

Capability64%

Pathways8%

Care Settings3%

General/Other25%

Blueprint capability ideas submitted by sites

Early topics – beginning to build the portfolio

Care setting

• Paper free A&E via active clinical noting

• EPMA in high secure services

Care pathway• Digitising care pathways

• Delirium and dementia electronic assessment

• Management of acutely disturbed patients

• Online improving access to psychological therapies

• Blood transfusion safety

• Oncology e-prescribing integrated with an EPR

Digital capability• Patient portal digital capability

• Introducing EPMA

• Vitals clinical observations

• Therapeutic observations

• Integrated paperless orderables

• Digital dictation

• Transfer of care documentation

• Results management – electronic results

• Barcoding breast milk

• Mobile app to help young people with behavioural and mental health needs

• AHP clinical documentation

Infrastructure, readiness and capability

• Mobilising the workforce

• Collaborative governance work across trusts

• Delivery approach, governance and benefits strategy

• Chief Information Officers clinical leadership structure

• Business intelligence - clinical dashboard

Larger scale projects• Paper free health records

• Population Health Management

• Patient flow and bed management

• Cerner implementation across two trusts

• Local record sharing via the Medical Interoperability Gateway (MIG)

How they will be made available and promoted?

• A digital platform that allows makes it easy to find and use blueprints

• Active promotion through a range of existing channels

• A learning network - supporting the NHS on digital transformation, working across programmes

Initial questions or reflections?

Wider Blueprinting user / reference group

(around 50 members but could be expanded depending on subject matter discussed)

BLN Steering Group

(around 25 members)

BLN core planning team

(6-8 members)

Listening to users – our

new oversight arrangements

We’d like your feedback

Do you think the proposed new shape for the Steering Group will be effective in continuing to support the national blueprinting work stream?

Would you suggest any changes?

Would you like to hear more about the work of the Steering Group?

Would you like to get involved – for example, join the user /reference group and help us to shape future blueprints?

Bringing it alive – presentations followed by Q&A

The blueprint on e-Sepsis created by Royal Liverpool and BroadgreenUniversity Hospitals NHS Trust (a clinical pathway)

The blueprint on Closed Loop Barcode Medication Administration created by Cambridge University Hospitals NHS Foundation Trust (a capability)

The Royal Liverpool and Broadgreen University Hospitals NHS Trust

e-Sepsis Blueprinting

• Our blueprinting journey started in December 2017 as a pilot site for the GDE Blueprinting programme.

• Our focus was on the process and outcomes we followed to deliver a digital care pathway for sepsis.

• Our blueprinting team was comprised of our clinical lead, specialist nurses and digital transformation experts. Co-design was key.

Our journey so far

Dec2017

Jan2018

Feb2018

Feb2018

Mar2018

Apr 2018

Digital Liverpool confirmed as pilot

site for Blueprinting

Digital Liverpool Blueprinting Team

Assembled

Blueprinting Data Collection

Blueprint Draftinge-Sepsis Blueprint

Peer Reviewe-Sepsis Baseline

• A clinical decision support tool to increase screening for Sepsis and subsequent antibiotic administration.

• An integrated digital care pathway that builds on our electronic health record.

• Sepsis is a serious and frequently occurring condition but early recognition and treatment can save lives.

• Our ambition was to decrease sepsis mortality rates for our patients.

The human factor: The UK Sepsis Trust estimates that 44,000 lives per year are claimed as a result of sepsis.

Why blueprint e-Sepsis?Ambitions for a digital care pathway

Delivers value:

- £300K saved through reductions in median LoS.

- We forecast 200+ avoidable sepsis deaths

11% reduction for septic

shock

14% reduction for severe

sepsis

2% reduction for sepsis

100% of patientsscreened within 1 hour of hospital admittance

Antibiotic prescribing <1hr in ED has increased from 65% to 85%

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Why blueprint e-Sepsis?Outcomes realised as a result of our digital care pathway at the point of blueprinting

• Identifying a clinical champion was key with a focus on patient outcomes.

• Engaging a diverse team of specialists at the outset.

• Securing executive buy-in at the start ensured focus and helped with risk mitigation.

• Ensure the conditions are “ripe” for implementation.

• Engage ward managers and other senior nursing /medical staff outside the core team for a different perspective.

Planning and PreparingBuilding the case, securing support and validating pathways

ImplementingCollaborative approaches to digitisation

• Devise clinical pathways and exceptions before digitisation.

• Use of a pilot phase before implementation enabled us to catch and fix problems.

• Training at the point of care rather than in the class room delivered results.

• Reinforcing the purpose of e-Sepsis aided uptake. We branded e-Sepsis not a tool for individual compliance or corporate KPIs… but as a tool for patients.

Local / Regional Roll Out

National Sharing

InternationalSharing

• We continue to monitor e-Sepsis performance at a local and Trust-wide level. We deliver positive interventions with our central sepsis team where required.

• We continue to innovate on a local level with our staff – e.g. use of text messaging to alert.

• Dissemination of lessons and our experience with regional, national and international partners.

SustainingContinuous improvement and spreading innovation

ReflectiveOur reflections on the pilot blueprinting programme

Reflective 3

Be frank and open in a reflective. Most found our challenges of use.

Reflective 4

Engage peer reviewers earlier in the development process.

Reflective 1

Blueprint as you go, not only at completion.

Reflective 2

Engage a multi-disciplinary team at outset. Co-design and reflection.

Global Digital Exemplar

BlueprintingClosed Loop Barcode

Medication Administration

@my_eHospital

Carolyn CrooksHead of Information Management

The Trust

• Two hospitals – Addenbrooke’s & the Rosie

• 5 clinical divisions – women’s healthcare fully integrated

Blueprinting BCMA

• December 2017: CUH agreed to be part of the GDE blueprinting pilot project.

• Aim: to define the framework, methodology and publication strategy for GDE blueprints.

• Scope: provide insights to shape a proposed design and subsequent process for developing blueprints.

• Requirement: to provide dedicated resource involving project management, collating/authoring and subject matter expert input.

• Vendor neutral, process based and not discussing the technical elements of the implementation

Clinical decision support16% of allergy-related prescribing

alerts lead to a change in prescription= 850+ significant adverse medication

reactions prevented (2,450 bed days saved)

e-Prescribing including clinical decision support & medication

administration chart

Electronic prescribing100% reduction in sedation-related prescribing errors in paediatrics = 50 intensive carebeds & 100 regular beds saved / year

Computerised Physician Order Entry 96% of all medication andinstruction orders nowcompleted electronically in our Epic EPR

Financial savings £1.2 million average annual reduction in the financial gap between high-cost drug expenditure and income.

Patients don’t stay in hospital for longer than necessary50% reduction in the time taken to prepare discharge medications as the EPR now integrates directly with the pharmacy robot

Improved antibiotic stewardship 100% recording of the indication for antibiotic prescribing within our Epic EPR

Safer Medication Processes

1. Fully integrated electronic patient record system including prescribing, clinical decision support & medication administration chart

2. Coded electronic medication database

3. Barcode Medication Administration (BCMA) & blueprinting to support other healthcare organisations

BCMA - scanning for safety

• International best practice for improving safety of medication administration

• Simultaneous scanning of a patient’s barcode wristband and medication barcode

• Connected to mobile / handheld devices and electronic medication administration chart in Epic EPR

• Protecting patients from prescribing, dispensing and administration errors

• Supports nurses in confirming five ‘rights’ of medication administration in real time

• Implemented on 18 wards• All inpatient areas by June 2018• Working towards HIMSS Stage 7

validation

Improved safety 50% reduction in medication errors

Planning and timing

Not implemented as part of EPR “big bang”

- Managing the rate of staff process change

- Requirement for dedicated resources

We learnt from others

- Visits to Sunderland Royal Hospital and Radboud UMC (Netherlands)

Assess the workflows and resources

- Map the ward layouts and the workflows

- Carry our hardware assessment.

Developing a medication barcode database

• Within the UK there is no national registry of barcodes for

medications at this time.

• For the pilot phase CUH created our own database using the First

Databank (FDB) Multilex drug database.

• Manual EPR codes were created and matched to medication profiles

for any medications not represented.

• Work with the FDB was expanded post pilot to include “Chemist and

Druggist” to give greater coverage.

Most complete drug barcode database in any NHS trust

Coded medication database

dm+d compliant

55,000 barcodesChemist & Druggist,

First DataBank

Matches all prescribed orders &

dispensed medications in EPR

Built in-house within the Epic EPR

Reporting, inter-operability

& PEPPOL standards

NHS England are forming a new national drug registry for all NHS trusts based on

our methodology

Training – the pilot and beyond

We created training which reinforced the CUH patient safety vision.

• For Ward Staff – scan the patient, scan the medication

• For Pharmacy – verify labels and medication

Our training policy developed as the programme progressed.

• Train medical staff about the importance of BCMA

• Utilise respected medical peers to support training

• Medication inclusion and exclusion criteria became enhanced.

Pilot phase on a single wardChose to pilot the programme on a paediatrics ward;

• Engagement and leadership

- The ward had a Senior Sister who was motivated to drive the project

forward

• Staffing

- Consistent staffing, low staff turnover and low reliance on bank staff

• Prescribing patterns

- Complex ward with range of prescribers

• Medications and volumes

- Medications used were consistent with low volumes of drug

administration.

Implementing the pilot phase

• Go live was scheduled to cause minimum disruption on the ward

• “Average” Monday morning, at 11am

• Dedicated trainers on the ward to answer questions

• Pharmacy support available to troubleshoot medications

• Support, communications and monitoring

- Individual support

- Ward team huddles

- eHospital technical huddle

- Compliance monitoring

Roll out• Roll out planned according to workflow and technical capability

• Remaining areas went live in three “big bangs”

• Pilot process was repeated

- Mapping of ward layout and workflows

- Support using huddles

• Nurse training was adapted based on staffing factors.

• Feedback mechanism developed between nursing and pharmacy

staff

Benefits and outcomes

• Clinical Outcomes

- We have a richer view into medication-related patient safety

• Operational Benefits

- BCMA is cost-neutral in terms of staff time and medication costs

- Nurses satisfaction – nurses feel “safer”

- BCMA has given increased visibility into medication compliance.

Lessons learnt from BCMA Implementation

• Start with a steering group

• Keep a clinical focus

• Communicate your vision for patient safety

• Document learning from the huddles

• Group your wards by workflow

• Share your data

• Understand that each roll out gets easier

• Recognise the limitations.

Lessons learnt from Blueprinting

• Enables reflection.- Did we make the right decisions?

- How were those decisions made?

• Encourages good project management methods.- Document the process

- Peer review

• Requires commitment to the programme.

- Dedicated resource.

What our nurses say… “BCMA is helping to reduce the possibility of drug errors on our ward and it’s really simple to do. Using a handheld digital device I scan the patient’s wristband which automatically brings their

medication chart in Epic up on the screen. I then scan their medication and their wristband again to double-check that I am about to give the right medication to the right patient. This provides an

added patient safety check and also makes me feel safer knowing that I’ve given my patients their correct medications and dose at the right time and in the right way.”

Clare O’Riordan, Staff Nurse, Care of the Elderly Ward

“Scanning of a patient’s medication and wristband together is really helping with patient safety on our ward. Nobody likes the feeling of unintentionally making a drug error and barcode medication

administration significantly reduces the risk of this occurring. If you scan the wrong medications for a patient the device will sound an alert and if you take the scanned medications to the wrong

patient it will again sound a warning to alert you that you have got the wrong patient.”

Hannah Nunn, Senior Sister, Paediatric Ward D2

Reflection: What you would like to see from blueprints to help support your digital transformation

Questions and suggestions?

Through what channels would you like to find out more about GDE Blueprinting?

• Dedicated Blueprinting website or platform

• National websites e.g. NHSE, NHSD, NHSI, HEE, etc

• Innovation or learning websites e.g HEE Star, Academy of Fab, Digital Academy

• Email cascades• National e-bulletins and newsletters• Regional / local e-bulletins and

newsletters

• Social media• Trade press• National media

• Online forums (such as CIO / CCIO / CNIO networks)

• Events

• Site visits and meetings

Thank you

To get more involved in blueprinting or share your

views please contact:

england.gdeblueprints@nhs.net