Workstream 1:

Project Management –

System Configuration

and Business as

normal

Andrew Heed

Kathy Wallis

17 June 2013

Agenda

• Some background to us – Trust and ePrescribing Project

• Workshop structure– Pre-Go Live planning

– Roll-out considerations

– Maintenance and Support

• Any questions??

University Hospital Southampton

• 1100 beds

• Provides services for 1.3M people in Southampton and south

Hampshire

• specialist services such as neurosciences, cardiac services and

children's intensive care to more than 3 million people in central

southern England and the Channel Islands

• major centre for teaching and research in association with the

University of Southampton and partners including the Medical

Research Council and Wellcome Trust

• treat around 140,000 inpatients and day patients, including about

50,000 emergency admissions

Project timeline

Newcastle upon Tyne Hospitals

• Freeman Hospital• Transplantation, Cancer Centre, Cardiothoracic Surgery, ENT, Vascular……

• Royal Victoria Infirmary• Neurosciences, Emergency care, Children’s Services, Plastic Surgery,

Ophthalmology, Dermatology, Maternity

• Beds – 1792 (Inpatient) & 205 (Day case)

• Activity– Inpatients – 192,000

– Outpatients – 870,000

– Lab/ Rad requests – 3 million

– ePrescriptions – 1.7 million

– eAdministration – 7.2 million

ePx Project

• Cerner Millennium system– ePx, electronic orders, A+E, Theatre

scheduling, PAS, documentation.

• Project timelines:– Work started April 2008

– Go-live November 2009

– Adult In-patient rollout completed March 2011

– Paediatric ward Feb 2013 (ongoing)

– Starting 2nd system upgrade.

– Documentation ongoing.

– Never-ending story

Workshop Session 1

Pre-Go Live Planning

• Design Considerations

• Testing

• Hardware

• Roll-out plan

• Training

• ….

Workshop Session 1

Feedback / Discussion

Design Considerations

• The drug catalogue– VTM, AMP, AMPP

• Terminology– Routes, forms, frequencies.

• Decision support.– Dosing sentences.

– Alerts (interaction / dose checking / allergy others)

– Order sets

• Future -proofing

Scope

• What can you actually do?

– System limitations

– Do you need documentation

• Where can you do it?

– Other systems?

• What can you afford / support.

Hardware

• Can you ever have enough?

• What kind?

• Dispensing trolley?

• Security / cleanliness / durability.

• People will have better hardware at home

– Or even in their pocket.

– But what can an App actually do?

Training

• Who to train?

• When to train?

• What to train on?

• How many people?

• How to get bums on seats?

• What about the night shift?

• Who will do this in the long term?

• Should we even bother?

Workshop Session 2

Roll-Out Considerations

• Support

• Mixed Media Prescribing

• Bank and Agency Staff

• Real time PAS / ADT issues

• ….

Workshop Session 2

Feedback / Discussion

Roll Out planning

• Start upstream or downstream?

• Time between wards go lives – transfer of patients and outliers

• Dual systems – paper and electronic

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Roll Out planning

• Big Bang vs staggered rollout.

– What can you support?

• Staggered:

– Arranged by directorate, patient flow

– How does geography affect things

– What is your transfer mechanism

– Is it realistic

– Too fast or too slow.

Dedicated ePrescribing support 24/7

• ePrescribing team manager (Pharmacist) plus 5 full-time team members (Nurses or

Pharmacy Technicians)

• On-site 24 hour support for 7 days post go live; otherwise 0730 – 2300 on site and

on-call over night

• Used extra support for Theatres when surgical wards first went live (anaesthetists

and recovery staff)

• Bank staff to support staff shortages

• Moving to be able to provide less on-site support over weekends

• Key success area for the project: awarded ‘Hospital Heroes’ team prize of Education

and Support

Agency nurses and locum doctor access

• Use NHS professionals and multiple other agencies

• High agency usage – wards could not operate if agency staff not able to use the

system

• Agreed process where agency nurses (and locum doctors) access and complete

training before starting their first shift

• Agencies responsible for completing System Access Forms

• Built into the performance metrics for the agencies

• Difficult for first few wards, but easier as more wards are live

Real-time ADT

• Was an on-going issue for the Trust to have a accurate electronic bed-state

– not a clinical task

• With ePrescribing:– Patient must be admitted to be able to administer medications (can prescribe if pre-admitted)

– If patient not admitted or transferred to the correct ward, they do not appear on the list of

patients due medication

– If patient not discharged, they will continue to appear on list of patients due medications –

each ward needs to clear all non-administered medications overnight to be able to administer

medications the next day

• Nursing staff now complete ADT when ward clerk not on duty (also have a

central ADT team to support)

• ADT available on the drug trolleys – therefore can complete transfers etc

‘on the fly’

• Also supports the use of other systems (e.g. Doctors Worklist; Bed

Management tools

Workshop Session 3

Maintenance and Support

• Responding to incidents

• Handling prescription errors

• On-going maintenance of the system

• Training

• Managing Expectations

• Reporting

• Data for audit

• Upgrades

• Downtime

Workshop Session 3

Feedback / Discussion

Responding to Incidents

• We now have something to blame!

• Who does this now? Who does this after go-live?

• System fault? or user fault?

• But what is the system?

– software, user, computer, Wi-Fi, power cable, the workmen

digging the road up 3 miles away?

• Trend monitoring.

• Feedback to users / training central team or department.

Consultant review of the drug chart / Drug

Chart Viewer

• surgical consultant ward

rounds

• anaesthetist review pre

procedure

(Demo)

On-going modification of build

• Link to stock control system limits naming of prescribable items:

– Inclusion of strength and formulation

• Modification of existing protocols – general prescribing practice is more

open

• Increasing list of protocols – standardise care and ease of prescribing

On-going maintenance

• Everything goes through the system

– New policies

– Clinical trials

– Who designs or build this

– Can the system / team become a bottleneck?

• How do we handle changes to the system?

– En masse change vs drip feed.

– How does the system handle change?

– Change control

• Do we need a down-time.

Future Proofing

• Try to plan for every area you will be going to….. Or you

potentially have a large rebuild / renaming process

• Try to take the long view and avoid short cuts.

• ???

Benefits: Error rates

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

1 2 3

Error Type

Wrong Route

Missed Dose

Wrong Freq

Wrong Drug

Wrong Form

Wrong Dose

No Duration

No Indication

Duplicate

Illegible

Wrong Instructions

0

2

4

6

8

10

12

Wrong

Dose

Missed

Dose

Prep

Error

Rate

Error

Wrong

Form

Wrong

Time

Administration Error Type Pre and

Post EPMA on C5 and G9

Period 1 (Pre)

Period 2 (Post)

Period 3 (Post)

Benefits: Drug Round times

Drug

Round

pre / post

eprescribing

Avg time / patient (Mins)

Avg difference

(mins / patientWard 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8

am

pre 11.49 7 7.95 6.45 6.91 7.31 8.6 8.15

post 6.47 6.17 7.57 6.18 7.07 6.88 6.7 9.47 0.92

lunch

pre 8.68 3.75 4.71 3.43 3.82 4.08 10 4.12

post 3.15 2.73 4.11 3.11 4.47 4.19 3.72 3.7 1.67

Eve

pre 9.21 5 6.05 4.53 3.96 6.63 5.85

post 5.21 4.53 3.45 4.36 5.5 3.25 3.37 4 1.68

Night

pre 10.47 5 4.26 4.81 4.5 5.47 12.65 8.71

post 5.78 6.42 4.9 5.43 5.39 6.45 9.38 10.57 0.19

Prescribing of Ceuroxime Whole Trust

0

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(bla

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2009 2010 2011 2012(blank)

Month

No

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f o

rders

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UNDER 65

(blank)

EN_LOC_NURSE_UNIT_DISP (All)

Count of Month

Year Month

Age range

Prescribing of Ceuroxime in A+E

0

10

20

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11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01

2009 2010 2011 2012

Month

No

. o

f o

rders

65+

UNDER 65

EN_LOC_NURSE_UNIT_DISP A+E

Count of Month

Year Month

Age range

Graph of C Diff incidenceJa

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Questions?