Tag:

CNIO Handbook

CNIO HandbookFeaturedNews

CNIO Handbook Final chapter

by David Teece
written by David Teece

One of the very first things I ever did in clinical informatics was to build a team of outstanding people.

In 2015, shortly after becoming director of development at Barts Health, an informal steering group of nurses who – like me – wanted to make sure the nursing voice was heard in digital projects was formed.

A few years later, I’d formally add the chief nursing information officer role to my responsibilities. But the importance of teamwork has never changed.

Getting a clinical informatics project off the ground, and then running effectively, can never involve only one person. It needs involvement across all clinical user groups (each of which may have slightly different needs and priorities) as well as across the IT side (both the internal IT staff and those working vendor-side). It needs, in short, teamwork.

Negotiation and trust

For me, that means that personal leadership style is key to success in the CNIO role. I’m very committed to collaboration, participation, and facilitation that enables an understanding of where everyone’s coming from. I like to build on the strengths of a team and create a strong user voice, bringing people together through engagement and towards a shared goal. Helping teams to be truly empowered in their digital development and journey is also important to sustained outcomes, growth of talent, and the satisfaction of team members.

That probably sounds like it’s straight out of a textbook. But all I’m really saying is that success in the CNIO role is about how you negotiate with people and how you build collaborative trust. It’s about making sure that teamwork is inclusive and builds understanding across all domains of the health informatics world. That way, you get the best out of the technical and clinical aspects of people’s skills and responsibilities.

I have expertise in, and a strong passion for, the development of outstanding care, nursing practice, the NHS, and organisational development and transformation. I’m not an IT technical expert but the NHS Digital Pioneer Fellowship and further training and development have really helped to expand my skills, critical thinking and system knowledge. The Digital Health CNIO Network, Summer Schools and regional CNIO groups have also been fabulous sources of rich information. So over the years I’ve developed skills in health informatics and recognise the opportunity to bring together a multi-professional team and enable a shared perspective on the digital solution. It makes a real difference to adoption if the patient and user voice are part of the team and early co-design – bringing in creative ideas and positive momentum and a satisfaction in the work. Really understanding what matters to everyone as part of the programme team is essential. By working and learning together, we get the best possible outcome.

The importance of identity

We have built an excellent clinical informatics team at Barts Health as part of a programme we call “We Connect”. Having a brand and team identity has been a positive motivator. The progamme is recognised across our group of hospitals, not just for digital transformation but for an energising approach to teamwork and change implementation methods.

The CNIO role is a lovely combination of clinical insight, health informatics and the ability to enable people to want to come on board. It’s about the ability to collaborate to enable often large-scale change and digital transformation, to reduce unwarranted variation and simultaneously achieve positive quality improvement. The core is engaging people at the heart of the development and raising the profile of health informatics, as well as bolstering digital competence and capability among fellow clinicians.

Negotiation skills are important in working with the team and wider workforce. Making sure the changes and developments really reflect excellence in the clinical workflow and are clinically led is crucial. Listening to teams, understanding what they need and then helping them to get it is important. Getting people involved early helps get a good balance between generic and specialist requirements and enables a seamless design. Building a wider team including super-users, digital champions and ambassadors does much to extend knowledge, skills and involvement and they are a fabulous positive energy and resource for wards and services. When people are part of the solution and can share in the improvement it all changes for the good.

That informal steering group created back in 2015 has grown to become a formal nursing informatics infrastructure. We have a nursing informatics officer at each of our four main hospital sites, a deputy and a lead informatics nurse, and then hundreds of super users. I report into the chief nursing officer, meaning informatics is central to nursing at the trust and have a close working relationship with the CIO and CCIO. The collective clinical informatics leadership team has a strong bond and the support has been truly amazing.

Our teams played a huge part in successful implementation of the electronic prescribing and medicines administration (EPMA) project back in 2021 and designed new functions and workflows right through the complexities of covid waves. This has built on our earlier implementation work, enabling digital development in nursing across the whole Barts Health Group. We have EPMA pharmacists and digital midwives, a growing allied health professionals informatics group, and medical clinical informatics leads too. We’re all continuously working together with our clinical systems and IT colleagues to enhance outcomes for our patients and our communities.

Build your rope team

During the We Connect nursing programme, I was reminded of a presentation I’d heard several years before. When we were implementing our Cerner EPR, we went as a team over to their headquarters in Kansas for a conference. One of the speakers was Erik Weihenmayer, the first blind person to reach the summit of Mount Everest.

His inspiring presentation introduced us to the idea of a rope team – the people who are with you as you adventure; who will save you from falling. It was an idea that really stuck with us as a nursing informatics team. Any time we implement a new digital project, we’re really clear about who is on our  rope team. As we began to implement the EPMA project, I received a postcard from one of the teams involved. It was a picture of climbers on a rope team. There was something really nice about that – about people feeling they were part of a team in which everyone had one another’s backs and sharing that same adventure.

Our team has expanded over time and there is a strong core of people who have really developed nursing informatics. We continue to integrate health informatics in everyone’s day, helping others to take their careers forward through the likes of fellowships, mentorship, coaching, our What Good Looks Like Strategy, and shared decision-making councils. They are true health informatics ambassadors and signal the very best of nursing and its impact. I am proud to work with such an amazing team of professionals.

Louise Hicks is CNIO and director of development at Barts Health Trust, one of the largest NHS trusts in England, and a visiting professor at City University of London. She became CNIO at Barts in 2019, having initially joined the trust as an improvement and transformation programme director. Louise previously worked in higher education and in clinical practice, of which she has over 40 years’ experience.

Back to top

0 comments
0 FacebookTwitterPinterestThreadsBlueskyEmail
CNIO HandbookFeaturedNews

CNIO Handbook Chapter 6

by Michele
written by Michele

The CNIO role is often seen as a link between nurses working clinically and the IT department, but in my case it also involves being a link between two recently merged trusts covering acute and community services.

Differing approaches to informatics

The previous organisations had taken very different approaches to informatics. One had an electronic health record (EHR) used for all nursing documentation, with care planning having been completed electronically for around 20 years.

The other trust had a ‘best of breed’ style, using a number of smaller systems for specific tasks. Large parts of the nursing documentation, including care planning, had remained on paper.

The two organisations merged in April 2019, and a decision was made to implement the EHR across the entire trust. That implementation was relatively straightforward and on the whole was well received, but two large groups of nurses coming together to work on common documentation did highlight areas where work was required.

Care planning was the noticeable aspect where refinement was needed. The nurses who were new to electronic care planning spotted imperfections in the use of the system. Those who had used it for many years had often just learnt to work around those imperfections – but in so doing, it meant care planning wasn’t always as effective as it could be.

Simplifying documentation

For me, the care plan is the most important aspect of the nursing process. If we don’t have a plan our success is purely down to chance. If we don’t identify a goal or outcome how do we even know that we have succeeded? How can we compare the outcomes of our care with our peers, whether in the same organisation or beyond? Making sure the same care plans are used consistently helps reduce variation – everyone works to the same goals and the same outcomes, which improves patient care.

To make documentation and care planning work for nurses, and ultimately benefit patients, we need to make assessments and plans as easy to complete as possible. That includes using digital systems. As CNIO, I’m therefore currently undertaking a review of care planning across our trust.

The staff nurses who use the documentation on a regular basis are best placed to say what needs to be improved in the current system and to review and comment on suggested changes. On that basis I set up a project steering group with representatives from both hospital sites and a range of staff roles, including staff nurses in band 5 and 6 roles from a range of medical and surgical specialties, ward managers, matrons and IT.

The three key areas for improvement

The group met to debate experiences of using electronic care plans. It became clear there were three key areas for improvement:

  • How we use the electronic care planning system. Traditionally, we have used our care planning system to record and evaluate whether standards of care – support with hygiene, for instance – has been delivered. That’s meant nurses have had much less time to actually use the care plan functionality, and means we’ve never used the software’s ability to evaluate a patient’s care against a care plan.
  • The number of plans. We currently have 150 care plans. Some are automatically digitally activated for a patient but, if a nurse needs to add an additional plan, he or she has to search through the full list of plans. You either have to scroll through to try and find the one you need, but the names aren’t always as clear as they might be, or search. While nurses who have used the system for a while have got used to these imperfections, those who are new to the system pointed out that this was really challenging.
  • Training. It was felt specific training should be offered to nurses to make sure they were comfortable with how the digital care planning setup worked, as well with the general clinical practice around care planning.

I have also connected with fellow CNIOs and digital nurses to discuss the care planning. Via the Digital Health CNIO Network Discourse, I’ve understood that this planning is challenging for many nurses, regardless of whether a digital of a paper-based system is used. The issue is often one of time. I can therefore see that while digital working can help, there is also a practice issue – and that, as CNIO, I may need to look beyond the informatics element to truly transform care planning in the trust.

The organisation currently has around 150 separate care plans. Even though these can be completed digitally, there are so many that it is difficult for nurses to select between them and know the right one to use in the right situation. Our steering group has now identified around 30 subjects on which we think we need to focus plans, and we have ‘subject experts’ working on these.

We have also reviewed a different process for evaluating care plans within our EHR. This will place a greater emphasis on evaluating the care that has been given against the care that has been planned. There is the ability to do this within the care planning software, but we’ve nor previously used it. My plan is to pilot using it across a couple of wards to see if we might be introduce its use consistently.

What has been really important to my work so far on this project has been having the support and direction from the senior nursing, midwifery and allied health professional team. Around the time the trust merged, I was working as a nurse consultant in an operational role and giving what other time I had to the CNIO role. At that point, the CNIO reported into the IT team.

The benefits

The merger made the CNIO role more important still and so, with agreement, it moved to be part of the trust’s corporate senior nursing team reporting directly to the director of nursing. This meant I could support the team in understanding the importance of digital nursing, and the opportunities it provides, but also that I could understand the nursing priorities for the organisation. The team also offers me real support in implementing changes, like those to care planning.

The shared decision making approach with the steering group has also been very important. Feedback of clinical staff as the end users of the technology has led to some excellent and well received improvements in our electronic health record. I remember one particular example when we’d introduced an assessment for patients who were at risk of self-harm or falls and needed one to one nursing care, or to be in a bay where a nurse was always present. The idea was that, on a two-hourly basis, staff would record what support and interactions had been provided.

In conversations with teams, we heard that these assessments were typically completed by healthcare assistants – and clashed with the intentional care rounds they were completing. So we moved the document in the EHR so it sat within the care round checklists. By doing that, we moved from 20-30% completion of the assessment to around 90%.

We are fortunate that our EHR can be adapted to the way in which we work: we don’t just have to use a one-size-fits all, off the shelf setup. We can build and edit documents and assessments in a way that we find useful. The shared decision making process will help ensure that any changes we make to the digital care planning process enable nurses to provide good quality, safe care, in an efficient and secure way.

About the author: Melanie Robertson is chief nursing informatics officer and cancer lead clinician at South Tyneside and Sunderland NHS Foundation Trust. She initially took on CNIO responsibilities in 2018, reporting to the IT team. In February 2020, the role moved to report to the director of nursing. Melanie has been a registered nurse since 1994.

Back to top

0 comments
0 FacebookTwitterPinterestThreadsBlueskyEmail
CNIO HandbookFeaturedNews

CNIO Handbook Chapter 3

by Michele
written by Michele

Back in 2015, Great Ormond Street Hospital for Children NHS Foundation Trust – a small but mighty specialist paediatrics trust – set a vision for its digital future. We were to introduce an electronic patient record (EPR): “An integrated system to be used by all staff, in all settings that will allow patients access in every interaction and hold the entire patient record.”

I’d worked at the trust since 1997 and, when this announcement was made, I was working operationally but also on a project to introduce electronic observations to the organisation. That led me to being approached to join the procurement team for the EPR, and into months of Excel spreadsheets, understanding system build, system testing, site visits and networking.

When implementation of the system began, it soon became clear a chief nursing information officer was going to be important to success. I was appointed to the role in January 2018, during the groundwork phase of implementation – the go live date was set for just over a year later. I remember feeling excited about the challenge ahead but petrified of how I would lead the nursing workforce through this transformational change in such a short timeframe.

Three core values

In working on the implementation, I always had three core values in mind. The first was patient welfare: we needed to make sure that the introduction of an EPR didn’t interfere with the safety of our care and, indeed, that it helped staff deliver the best possible care to our patients. The second was operational improvement. We needed to make sure that the EPR helped us deliver care more efficiently. The final was staff engagement, which as CNIO was and is a key part of my role.

I knew that clinical engagement was key to a successful implementation. Clinicians would be the ultimate users of the system and so they needed to be part of the journey, helping us build efficient workflows. The design of the system had to be intuitive to staff, to reduce not increase burden.

There are a few key steps I took which made the task of implementation feel more manageable, and which I’d recommend to any nursing colleague supporting a similar project.

  • Create a team: Creating a team of nursing informaticians was the single best thing I did. Members had diverse backgrounds, skills and experience. That meant we were able to build an EPR that was tailored to the range of people in the organisation and the range of work they do: the different pathways and workflows, and also different levels of expertise in digital systems. We appointed a huge number of subject matter experts, who advised us on how the specific workflows in which they and their colleagues were involved should be reflected in the EPR. This has been important in making the most of clinical decision support functionality within the system. We’ve ensured the EPR supports clinicians in applying best practice in specific areas of care, but also that it allows diversion from that when clinical judgement requires. It means we avoid clinicians becoming fatigued by alerts about deviations from best practice that are in fact entirely justified.
  • Learn from others: I spent time making friends with both national and international colleagues who had travelled the journey before. These relationships definitely played a part in the success not only of the EPR implementation but with my development as a CNIO. The CNIO Network was a particularly important part of building these relationships and sources of support.
  • Take the opportunity to review how care is provided: Before we implemented our EPR, we had several different ways of documenting the same information. I saw the implementation as an opportunity to rethink this, and create new ways to care – introducing an EPR shouldn’t just be about digitising existing ways of working. We, for instance, created some functionality we call Essence. This is a means of entering a brief description of what a clinical note is about: it only takes 30 seconds and is up to 156 characters, a bit like a tweet. It means that any clinician looking through a patient’s record can quickly understand which clinical notes are relevant to current care – rather than having to open all of them and read through they can judge the most relevant from the summary.
  • Take every opportunity to communicate with clinical colleagues about the implementation: I invited myself along to every clinical meeting that existed across the trust to talk about the journey, where we were to date, and what we needed from the teams. I wanted the EPR to be at the forefront of everyone’s minds and for everyone to understand that the system was theirs – to use and to shape. We weren’t introducing a system to people, but introducing a system with them.
  • Focus on change management: This project was the single biggest transformation the trust had been through. There are challenges to leading a huge programme of change. The logistics of bringing an entire organisation on this journey, at the same time as staff are facing the normal day-to-day challenges, were far from easy. We appointed change managers to help here. They were trained to support the system design but more importantly the adoption and longer-term optimisation. When working on an EPR project, the go live is of course the main focus but there is so much important work that happens afterwards, once people have actually started using it. Sometimes it’s only then that you see how a workflow or patient pathway can be best represented on the EPR. Having operational teams feel they had ownership of the EPR, and could shape it over time, was a key part of our success.
  • Get training right: We familiarised staff with the system by giving them basic sessions on how it worked and tip sheets. We didn’t train them to use the system fully, because we knew that you only really learn how to use an electronic patient record when you actually start using it in practice.

The system went live over the 2019 Easter weekend. We went with a big bang launch, so the EPR was live everywhere across the trust. It was one of the highlights of my career – seeing months of work come into fruition in front of your eyes was fantastic.

Running the implementation

It was such a big transformation that, as an organisation, we ran the implementation as though we were confronting a major incident. This enabled staff to bring any issues directly to the implementation team to either be actioned or support given.

As a nursing leadership team we created what we called SWAT teams – small groups of experts who were dispatched to help with some of the more complicated process in the new EPR. Blood administration was an example: when we knew that someone had ordered blood, a SWAT team was dispatched to go and help the staff through the process using the EPR.

With all that said, my advice is to make an EPR go live a celebration. It’s one of the few times the whole organisation will come together to support a transformational change. The success of an EPR implementation goes beyond just putting the system in. For some clinical teams, the true value was only seen later, in the form of opportunities to improve services and continually improve the care we deliver. It is at this point that patients, families and staff start to experience the deeper benefits that digital transformation can bring.

“With all that said, my advice is to make an EPR go live a celebration. It’s one of the few times the whole organisation will come together to support a transformational change.”

Benefits

One big area of benefit is the availability of data. With all information being held in the electronic patient record, and the knowledge that it is robust information, we’ve been able to create clinical dashboards. These give staff an understanding of where things are going well and where they are going less well. This in turn means that we can standardise and improve clinical workflows.

I’m always working to engage my clinical colleagues in making best use of the system, helping encourage a curiosity about it can be used to the maximum possible benefit. Once that seed is planted – and nurtured within individual clinical teams – staff can start to use data to drive change themselves.

It’s an example of how EPR-related work doesn’t stop with a go live. It’s a journey but one that it’s a privilege to be on.

About the author: Sarah Newcombe is chief nursing information officer at Great Ormond Street Hospital for Children NHS Foundation Trust. She joined the organisation in 1997 as a staff nurse. In 2012, she became the clinical lead for the implementation of electronic observations at the trust. She has been CNIO since January 2018.

Back to top

0 comments
0 FacebookTwitterPinterestThreadsBlueskyEmail