Benefits Realisation – Reflections from Ann Slee & Bryony Franklin
Start by listening to NHSX’s Associate Chief Clinical Information Officer, Ann Slee, and the Director of the Centre for Medication Safety and Service Quality (CMSSQ), a joint research unit between Imperial College Healthcare NHS Trust, Professor Bryony Franklin, discuss what they want you to take from this resource, and how they want you to use it.
Your approach
Mix it up
Use hardware that is easily available and reliable rather than trying to procure a perfect set. And remember, no one type of kits works for all.
Identify the workarounds
People will always find their own workarounds for new systems, so spend time finding out what they are and why they seem to be needed. Remember that workarounds usually occur because there is something wrong with the process, not because the users are lazy or unaccepting of change. If a workaround seems more intuitive, evaluate it and consider embedding it into practice more safely. If users will do it anyway, help them do it more safely. Otherwise, work on supporting those who do them to better understand the process you would like them to use.
Optimise ward-by-ward
Although standard processes should be similar across the organisation (e.g. administration/prescribing/review/ordering/discharge process), there may be small refinements that can be made ward-by-ward to help them use the system. Reviewing ward-by-ward will also allow you to identify exemplars of good practice and superusers, which may be useful for future use/optimisation of the system more widely.
Assess the risks
Think about existing risks in your organisation that you can significantly reduce with ePrescribing (this is key to being able to measure benefits), but also about the new risks that the system may introduce.
Standardise terminology
New systems bring new vocabulary. Sometimes you need to translate and sometimes you need to assimilate new ways of describing processes. For example, with a pharmacist validation of prescriptions, is this a ‘clinical check’, ‘verification’, ‘screening’, ‘validation’, ‘sign off’ or ‘approval’. Getting language right can help overcome issues caused by interpretation in system language – if the supplier can only call it ‘sign off’ then the team need to understand this interpretation is what they previously called ‘validation’ for example.
Working with Data
Plan for analysis
Not only is there a risk that the data available could be overwhelming, but when the data available is more comprehensive than ever before, there will likely be a great desire to act on the information immediately. Managing expectations around the availability of all of this new data is difficult, but the challenge lies in identifying and ring-fencing suitable resource to undertake the necessary quality improvement in response to the data.
Distinguish between data types
It’s important to distinguish between data for performance / operational use and data for incident monitoring and investigation. The former is incredibly useful but needs lots of thought and resource to get right. The latter needs to be acted on more urgently and you will need to work out how best to respond to these while helping colleagues to get to grips with the impact of ePMA in medicines risk management. Be prepared to think about how to access and use the new data and resource and value this data analytics part of the change – it’s invaluable.
Define your baseline approach
Our network holds different views: some advocate a baseline data set so you are able to show where a difference has been made, other trusts have in retrospect advised against collecting baseline data as it can be difficult to do, and ultimately not the right investment of time. Reflect on your resource and business case requirements and any local benefits that may accrue from demonstrating early or late wins. There are pros and cons that you need to be fully aware before making any decision on approach. For example, the use of ePMA data may not be seen as a priority until it is available in large amounts, and you may not succeed in getting resource for this or even work out what you want from the data until after implementation is complete
Managing Alerts
Beware alert fatigue
Ensure the use of alerts is thought-through and revisited regularly to avoid alert fatigue. Look at the choice of alerts, which alerts are switched on, the timing of alerts, Hard vs Soft and user action as a result of alerts (i.e. do they acknowledge or just ignore, suggesting fatigue) to support you.
Ensure appropriate governance of decision-making
Alerts can have unintended consequences. Think about having an Alerts or Clinical Decision Support Working/Steering Group to ensure you have an appropriate decision-making structure in place.
Measurement
Know your timings
Measure the time it takes for a paper journey (e.g prescription from a clinician to the pharmacy) to see how time is affected by the e-Prescribing system. It might not be that this is a time-saving method for many roles, but knowing the difference will help you to manage expectations.
Think about indirect time too
Indirect time, such as physically transporting paper charts around a ward/hospital for normal activities, might be another area that ePMA saves time. However, also consider additional time which may be added by the new system, for example, if you don’t invest in additional hardware there may be additional time spent to access the ePrescribing system
Consider the impact on timing for patients
Identify if there is a reduction in time to receipt of medicines for an individual patient as well as the effect that the system has on staff time.
Culture, not just tech
Be open
Engage leaders in creating an open culture for reporting incidents so that system improvements can be made quickly and make sure to do this in partnership with clinical staff.
Identify champions
Do this early and ensure a range of users and seniority levels are included, have a clearly defined ‘champion’ role and expectations set out so it can be used as personal development for the individual
Value change management
When implementing ePrescribing you are not just changing from a paper chart to one which is viewed on a screen. You are changing most of the processes across the whole organisation, which have anything to do with medicines. Changing systems means changing how you work and how you care for patients.
Create leaderboards across wards
This can lead to helpful competition if handled well – but use with caution and context. For example, comparing doses administered with a 16-bed ward and a 50-bed ward is not appropriate. Instead, aim for standard based and proportional metrics such as ‘percentage of missed doses due to ‘medication unavailable’’ or ‘percentage of medications recorded within a one-hour window of due time’. Be careful not to alienate or demoralise areas that are not performing as well – there can be other determining factors for this.
Ensure education is ongoing
Design it and evaluate it. Have clinical champions. Have value and reward systems. Bring education to workplace settings, not just in classrooms. Get partner trainers and clinicians to come up with good scenarios that reflect real experiences.
Scope out hardware requirements
It can slow down your project or create problems later if you realise too late that a ward doesn’t have enough space/ power sockets/ network points/ wifi coverage etc.