Download June-17-2013-worksho..

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
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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:
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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
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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
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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
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Support
Mixed Media Prescribing
Bank and Agency Staff
Real time PAS / ADT issues
….
Workshop Session 2
Feedback / Discussion
29 M ay - 31 July
11 - 16 September
18 - 23 September
25 - 30 September
Division B Wards (18 wards)
Cancer Care:MAOS (Bay on C3);
C3 (Bay B), C4, C7, D3,
Cancer Care CMH
Cancer Care: C6
Neuro: F8
27 November 2 December
5 - 12 December
11 - 16 December
15 - 27 Jan
05 - 24 February
March - August
10 - 30 September
2013
July - December
2013
01 December 2013
?Autumn 2013
Surgery
E5, E7, E8, SDU(Surgery)
Cardiothoracic: D4 (Vascular)
Theatre 10
Woman's Surgical Unit
Bramshaw Woman's Unit, Day Surgical Unit
Theatres x 3 and Recovery: PAH
SHDU
Neurosciences: NICU
CNU, DNU, ENU, F8, Neuro-Radiology
Theatres: Neuro 1,2,3. Recovery: Neuro
Cardiac
D2, E3, E4, CHDU, CCU, CSS
Theatres: A,B,C,3,4,
Complete Paediatric Build.
V5.02 - test and install
Child Health
E1, G4N, G4S, PD / PDM, Neuro Paeds (G2),
Piam Brown, PAU, PMU, PHD / LTV,
Bursledon House
Theatres and Recovery: S,T
Outpatients
Maternity: Burley, Lyndhurst,
Labour Ward,
Broadlands, NFBC
Obstetric Theatre x 1: PAH
To be confirmed:
receive and test V5.1
Winter 2013 / 14
Process needs
agreeing
To be confirmed: Transitional Baby Unit, SCBU
NNU
To be confirmed: CDU / ?ED
Winter 2013 / 14
20 - 25 November
Surgery
ASU, F5, F6, F7
Theatres: 5,6,7,(11),13,14. Recovery: E Level
2012
To be confirmed:
Critical Care: GICU, CICU
Child health: PICU
618 November
Trauma and Orthopaedics: SDU (T&O), F1, F2, F3,
F4
Theatres: Neuro Barn4 & 5,,8,9,11, 12, h,j. Recovery:
F level, Neuro
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October
Period
Ward
Roll Out planning
Start upstream or downstream?
Time between wards go lives – transfer of patients and outliers
Dual systems – paper and electronic
2013
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
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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
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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
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Difficult for first few wards, but easier as more wards are live
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Real-time ADT
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Was an on-going issue for the Trust to have a accurate electronic bed-state
– not a clinical task
With ePrescribing:
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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
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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
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Link to stock control system limits naming of prescribable items:
– Inclusion of strength and formulation
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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
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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
Error Type
70.00%
Wrong Route
60.00%
Missed Dose
Wrong Freq
50.00%
Wrong Drug
40.00%
Wrong Form
Wrong Dose
30.00%
No Duration
20.00%
No Indication
10.00%
Duplicate
Illegible
0.00%
1
2
3
Wrong Instructions
Administration Error Type Pre and
Post EPMA on C5 and G9
12
10
8
Period 1 (Pre)
6
Period 2 (Post)
4
Period 3 (Post)
2
0
Wrong
Dose
Missed
Dose
Prep
Error
Rate
Error
Wrong
Form
Wrong
Time
Benefits: Drug Round times
Avg time / patient (Mins)
Drug
Round
am
lunch
Eve
Night
pre / post
eprescribing
Ward 1
Ward 2
Ward 3
Ward 4
Ward 5
Ward 6
Ward 7
Avg difference
(mins / patient
Ward 8
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
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
pre
9.21
5
6.05
4.53
3.96
6.63
post
5.21
4.53
3.45
4.36
5.5
3.25
3.37
4
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
0.92
1.67
5.85
1.68
0.19
EN_LOC_NURSE_UNIT_DISP (All)
Prescribing of Ceuroxime Whole Trust
Count of Month
800
700
500
Age range
65+
400
UNDER 65
(blank)
300
200
100
2009
2010
2011
Month
(blank)
01
12
11
10
09
08
07
06
05
04
03
02
01
12
11
10
09
08
07
06
05
04
03
02
01
12
0
11
No. of orders
600
2012
(blank)
EN_LOC_NURSE_UNIT_DISP A+E
Prescribing of Ceuroxime in A+E
Count of Month
60
50
No. of orders
40
Age range
30
65+
UNDER 65
20
10
0
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
Month
2012
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
Nov-09
Sep-09
Jul-09
May-09
Mar-09
Jan-09
Graph of C Diff incidence
Questions?