Introduction

I’ve known Sarah McGovern since she first started at university and began her education to become a physiotherapist. Roll forward a few, cough, years, and Sarah is the Director of Transformation at Manchester University NHS Foundation Trust. A few months ago, I was talking to Sarah about a project she had delivered at Manchester University NHS Foundation Trust. It was a fascinating project, in a very challenging environment, to introduce a new Electronic Patient Record (EPR) system that touches almost every aspect of day-to-day clinical operation. What’s more, when we spoke, the project had been embedded exceptionally well and a year down the line it was showing great benefits – this isn’t something you hear very often with NHS projects. Naturally I wanted to know more…

Tell me about Manchester University NHS Foundation Trust

“Manchester University NHS Foundation Trust”, began Sarah, “is one of the largest NHS trusts in England. It has 10 hospitals across the organisation and also community health and some social care services. So, delivery across the Manchester footprint of District General Hospital Services, which are more standardised NHS services, but also highly specialised, and specialist services as well as research and development”.

“Across the organisation we’ve got Manchester Royal Infirmary, Wythenshaw, and North Manchester general hospitals, which are adult hospitals. We’ve also got St. Mary’s clinical service, which is our women’s hospital and services, and that delivers across all of our sites. We’ve got the eye and dental hospital. We’ve got the Royal Manchester Children’s Hospital as well”.

“And then we have a function called CSS which is Clinical Specialised Services and what that delivers are our support services such as anaesthetics, AHPs, which are your therapists and Allied Health Professionals. Pain management services and pharmacy and labs; so that’s a big division, but it’s obviously present in all of our sites. And then we’ve got our LCO, which is our Local Community Organisation and that provides the Community Services across Manchester and Trafford”.

“It’s about 30,000 staff across the organisation and so large, complex and exciting, with loads of opportunities”.

There are indeed loads of opportunities in such an organisation. But the thought of delivering a technology project that spans all of those sites, teams, disciplines, ways of working, was already making me feel uneasy. When you couple this with life-saving work, sensitive data, potentially deadly drugs and complex health conditions, and the sheer number of processes that are required to run a trust of this scale, it is mind-blowing.

How Do Electronics Patient Records Fit into a Trust?

Unless you’ve been exceptionally fortunate in your life to never have visited a hospital, we all have a preconceived idea of what goes on inside those long corridors, soundproof curtain walls, and operating theatres. After all, there are plenty of hospital-based dramas and films that act as reference points. I had a preconceived idea of the role of an Electronic Patient Record system; medical staff would take notes, be able to view your previous notes and test results, and you’d be able to book appointments. Right? But, from what Sarah had already told me about the size, scale, and diverse nature of the Trust, I suspected there was more to it than that.

Indecision and delays are the parents of failure

• “We had a lot of paper records”. Most organisations I know would run a dedicated project to digitise their paper-based processes.
• “We had multiple clinical systems”. Most organisations I know would run a dedicated project to amalgamate those multiple systems.
• “Within that you’ve got inherent variation; even if everybody uses the systems in the same way, which we know that workarounds are really prevalent across every industry, a piece of technology doesn’t stop the human behaviour”. Again, most organisations I know would run a dedicated project to map those processes, identify the manual interventions, update the technology, and consolidate the processes.
• “We also had three different Patient Administration Systems (PAS) which is where you manage your waiting list and book your appointments”. You guessed it, separate project!

As you consider the four areas that Sarah highlighted, you can indeed see the complexity, but also the opportunities. Removing paper has many benefits; financial, environmental, confidentiality, storage. Maintaining one system rather than 80 has a huge impact on training, and support from IT. Updating and consolidating processes reduces tacit knowledge, variation, margins for error. Having a single PAS system provides a single view for reporting and Business Intelligence.

“What we have had the opportunity to do with a single electronic patient record is reduce the variation. When we built the EPR … we were able to do it in the same way for every site. We didn’t build it differently for Manchester Royal Infirmary and differently for Wythenshawe or North Manchester for example. The build is the build and so we’ve got the real opportunity of standardisation which improves efficiency, improves effectiveness, improves outcomes, because you’re able to apply best practice”.

This makes perfect sense. Why should hospitals have different systems and different processes and different workarounds if they are delivering the same services? Delivery of anaesthetics in one hospital should be the same in all of the others. In fact, if it isn’t, you’re more likely to have serious issues and potential danger to life.

“From a change management perspective” Sarah continued, “there is still a lot of work to do around human engagement and behaviour with the system, because they can still operate in work arounds with any kind of electronic system. But, in our programme we went from a go live position to stabilisation and we’re now moving into optimization. So, the huge amount of variation which we did have we’ve managed to reduce for patient benefit”.

What Aspects of Day-to-Day Operation is an EPR involved in?

I was really starting to get a sense of the complexity and opportunities that Sarah had mentioned. Whilst the opportunities were clear, I had a nagging doubt that I didn’t fully grasp all of the complexity yet. I wondered just how far an EPR system reached into the Trust, which departments and services would be affected by introducing a new platform.

“It is significant, and it does depend on where a starting point for a trust will be”. Sarah went on to explain, “when we’ve deployed Epic as a platform, it is an all-encompassing patient clinical record. So, for us, it is the whole patient journey. From the moment a patient enters the hospital, whether that be through A&E or through an outpatient appointment, etcetera, the whole journey for that patient is now recorded in the electronic patient record, which is one single version of the truth. What I mean by that is that is all the documentation by the doctors, by the nurses, by the therapist. But it is also asking for diagnostics like blood test or X-rays. That’s all processed through the same system and the results are processed through the same system. So, it is all absolutely accessible within one single patient record. Placing a referral, to then asking for an outpatient appointment is within the same system”.

As if introducing a new EPR platform wasn’t going to be challenging enough, with disparate locations, multiple systems, manual workarounds, paper processes, the new platform was also going to be involved in literally all aspects of a patient’s journey.

“We talked about having three different PAS’s before. Well, the PAS is central to the clinical records, so that’s now fully integrated. All the appointments are booked and scheduled so everything is linked to your waiting list, but also to your clinical record. So, the real benefit of that from a clinical perspective is that everybody can see everything”.

Clearly everybody can’t actually see everything, but the sentiment is correct. We’re talking about a hospital system where controls need to be tight, and access should be on a need-to-know basis. Almost every system I have ever worked on has had Role Based Access Controls (RBAC) to access relevant data. RBAC can actually be one of the most challenging aspects of a new platform, but again to do this within the complexity Sarah has already outlined, makes the project another order of magnitude more complex.

“Obviously you’ve got security settings, so you can only see what you need to see within your role. But if a patient attends Manchester Royal Infirmary on Thursday of this week, and then arrives at North Manchester general next week, the clinicians can see the same information. So, all the history of the treatment they’ve accessed, in one place, without having to request access to records or going into one of the plethora of systems that we had previously. What you’ve got is really easy access to real time data and information at the touch of a button”.

As a clinician going about your duties a single EPR must make a massive difference. There is one place to go to get all the information relating to a patient. Cognitive load must be vastly reduced. There must be huge time savings from using a single system. Accuracy must be much higher as you can make informed decisions from having all of the data at your fingertips. But what about the benefits for patients?

“From a patient perspective, what this means is less duplication from repeating your information. If any of us have been to any kind of healthcare appointment, you get asked the same questions all the time. That doesn’t mean that the clinicians won’t cross check information with you, because absolutely they have to. But one of the biggest benefits that we’re seeing from the patient record for the patient is we’ve got an integrated patient portal. The patient can access all of their results through the portal. They can see all of their letters. The letters sent to them and sent to the GP, for example, so any discharge summaries or outcomes and appointments. It’s immediately available to them through the portal. We have just started pilots for wider rollout around self-scheduling. So being able to book your own appointment, cancel your own appointment, move your own appointment, which is what we’re used to in everyday life”.

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How do you start to begin delivering this project?

I’ve been delivering challenging projects for over 25 years. I genuinely shudder at the thought of delivering Sarah’s EPR project. Multiple sites. Disparate processes. Paper-based processes. Over 80 clinical systems. Three PAS systems. Multiple levels of security. Sensitive data. Every aspect of a patient’s journey being impacted. Introducing the new platform whilst keeping all of the existing systems and processes alive to maintain life-saving procedures.

“Right from the beginning”, Sarah continued, “we were very clear as an organisation that this wasn’t a technological programme of work. It was a transformational programme of work that was clinically lead, operationally delivered, and digitally enabled through a platform called Epic. We had a really strong brand, and our brand was called Hive. Our strap line was ‘clinically lead, operationally delivered, digitally enabled’. We were really, really, keen for people not to think of it as a technological programme of work for various reasons mainly, well, not mainly but strongly, because success rates of technological programmes have been variable across the NHS. So that was one reason, but also secondly, people see it as somebody else’s job if it’s a tech thing”.

I think IT project delivery can be a hero or villain, depending on how the project engages its stakeholders. The majority of projects within the NHS have been delivered at the clinicians. Stakeholder engagement has been minimal – partly due to everybody being perceived to be too busy to engage, but partly due to project delivery ‘knowing better’ because they are technology specialists – this phenomenon isn’t specific to the NHS, by the way. But the approach of having a brand for a transformation project is perfect and I believe is one of the critical success factors for Hive. Hive makes it really clear from the get-go that the technology is there to support the clinicians – “clinically lead, operationally delivered, digitally enabled”. This is, ultimately, the role of technology – to support.

The point from Sarah about “people see it as somebody else’s job if it’s a tech thing” is also abundantly clear in far too many IT projects. It is easy for anybody to become disengaged with a project when they don’t understand what it is trying to achieve, or how. Many people don’t care about technology, they just want to do their job. If it can be made clear as to how technology can facilitate doing their job better, faster, more easily, then they will be engaged.

“From the day we flick the switch, every single person in this organisation’s job will change. Not in terms of their terms and conditions and what they deliver, but how they deliver their care to their patients”. Sarah again highlighted the impact of the new EPR platform and the core reason for creating the brand. “We set up a programme of work, and we were a 250 strong programme team, so that was recruited with some internal and a lot of external support, with a really structured programme”.

As Sarah begins to delve into some of the technical aspects of the programme, it was clear that a lot of thought had been embedded into the approach. “We talked about having 80 different systems. Well, that was clinical systems, there was a whole plethora of other data systems that contribute to reporting and operations. There was a huge piece of work around data quality, to reduce errors and duplicates, and other [data] errors had to be cleaned before data could be migrated across to the system. So that started quite early”. For me, integrations, and data quality and migration can never be considered too early in a project. This was another critical success factor in my eyes.

Another critical area for transformation projects is decision making. A poor decision is better than making no decision – even George Canning (1770-1827) knew this when he was quoted as saying ‘Indecision and delays are the parents of failure’. With such a complex transformation to deliver, not making decisions would be catastrophic. “When we moved into the Epic design … we had over 100 rapid decision groups across the organisation, where we had our Hive analysts, which is our term for people who build the system, with clinical people, operational leaders, BI and data analysts, transformation and change leads, and representatives from each of our hospitals that manage clinical services. They’re wrapped around making decisions, around how the pathway needed to be built within the system. We had over 100, which made decisions over a number of months. Once that decision was made, it was logged within the programme and official documentation and then the builders would then go and build the design”.

“Then we move into a huge piece of engagement with the hospitals and MCS’s, in terms of what does this mean for you in your working life”. We’ve already said how stakeholder engagement was so crucial, but now Sarah was talking about engaging with all of the users of Hive, which as we have discussed, is 30,000 users across the Trust. “We ran huge comms programmes. We had dedicated communications support for the programme. What we know is you can’t use one method of communication. Busy, busy people, particularly clinicians, who are working on a ward or in a clinic, they don’t check their emails. You can send them beautiful videos and presentations through e-mail, but actually we needed to do roadshows, drop-in sessions. We did even revert to what we would refer to as old fashioned posters to go on notice boards. So huge, huge, engagement campaign in terms of what will it look like in the future. What does this mean for you”.

Can you over communicate with such a project? EPR is clearly such a large scale, all-encompassing change that you can’t really leave anybody on the periphery. One department, one team that isn’t included could lead to serious consequences. I love the lengths that Sarah’s team went to, to ensure everyone felt involved and everyone was aware of what was going on. In a high-tech world, with a project that was underpinned by new digital technology, it was undoubtedly the low-tech comms that was having the most impact with the hands-on clinical staff. It was on their terms, in their world, which is predominantly offline.

“We had to set up what we called our operational readiness stream. There is a lot of work in terms of operational readiness for go live, and that ranged from ensuring that we had all of our clinic, so outpatient clinic templates built correctly”. There were also some low-tech solutions with respect to the actual operational readiness, “some of the data could not be migrated digitally, so that has to be manually migrated”.

But perhaps one of the biggest logistical challenges for the entire project, and anybody that has delivered any form of training at scale will understand the challenges here, was to train 30,000 staff during Covid restrictions. “We had a huge training programme and training 30,000 members of staff, face to face in classrooms was a huge challenge, releasing them from delivering their day-to-day work to attend training. We wouldn’t have been able to go live unless we had more than, I think it was 85% of staff trained. You have a threshold of training”.

“Finally we had our go live planning work stream, which was huge. We ran go live like a command and control structure and we were very clear we weren’t managing an incident, but we were managing a significant change, because we went live with all of our hospitals and MCS’s at the same time”. A ‘command and control’ structure is a type of management system that is characterized by hierarchical authority, a clear chain of command, and centralized decision-making. This type of structure can be very effective in environments where precision, uniformity, and adherence to policies and procedures are necessary. We’ve discussed the scale and complexity of the project many times now, but without this rigorous structure in place, things could quickly descend into chaos.

“So, 8th September, 4:00 in the morning”, which ironically was the same day Queen Elizabeth II died, and a date I am sure Sarah and the team will never forget, “the switch changes and we’re no longer using those 80 systems or paper, we are now using the electronic system. Delivering that with floor walkers, super users as command centres on each site to be able to escalate issues as they happen, in real time. Managing that is significant because in terms of a member of staff having an issue on a ward in a clinic, wherever their clinical area is, they don’t know whether it’s built wrong, broken, or actually is it user error, which is a terrible term, but actually is it just not knowing how to use the system? So a huge of amount of support needed on the frontline for go live, making sure you’ve got the right expertise out there to help those guys and girls managing it in real time”. I actually feel tense just thinking about those first few days! There’s no turning back after flicking that switch and your experience is only going to be as good as your planning and preparation.

I love Sarah’s casual, final remark as she sums up what I believe to be the most complex project I’ve heard about, “So, quite chunky” 😊

How Has It Gone?

Sarah’s response to the question of how the project has gone is great. Often leaders focus in on immediate cost, or time savings, but Sarah acknowledges the broad range of measures that all comprise the value of the new EPR platform. Moreover, the success of the programme isn’t being judged on immediate, perceived benefits, “We’re very clear this is a 10 year programme of work, so our benefits profile is mapped over a 10 year profile. Obviously, we’ve got cash releasing benefits, as you would expect from any programme, but huge focus on our quality, safety, and patient and staff experience benefits”.

“With any programme of this size, as you would expect, it isn’t easy. So, the first few weeks and months are quite challenging. In fact, the first two to three weeks … go quite well because people are excited and there’s a little bit of adrenaline. We’ve got floor walkers and super users and actually, people are really engaged”. I wasn’t expecting Sarah to say this. With such a dramatic and instant switchover of so many systems and processes, I really did think it would be a nightmare for the first few weeks!

“And then you go through a bit of a valley of Doom, I think it’s called, in terms of kind of six to nine weeks out where people have still got issues, they haven’t necessarily been resolved, it feels so different to the old way of working. So that is a really challenging time and you need to make sure you’ve got the resource out there to support. The best, in terms of managing that, is communicating with people. If they’re waiting for an issue to be resolved, but you’ve got a queue of other issues, actually keeping people updated, which is really challenging when you’ve got such a large organisation”.

“Twelve months down the line, it’s not perfect, but it is absolutely brilliant”.

Sarah gave some examples of some of the benefits since go live, in addition to removing paper processes, 80 clinical systems, 3 PAS’s ………

• “People talk about not being able to remember not having it, which is brilliant”
• “Our patients, particularly those using the patient portal, absolutely do love it. Our patient cancellation rates for people using the patient portal are actually much reduced when we compare it to patients not using the patient portal. So actually, having access to that information and being able to self-manage is absolutely supporting that patient engagement”
• “We’ve seen real benefits in terms of some of our safety areas. Within the system, in the medication administration pathway, we’ve we opted to use the barcode medication administration system. What that means is if the doctor prescribes medication, before that is administered to you as a patient your wrist band is scanned. So, you’ve got a barcode on your wristband and the system says yes, this patient and the prescribed medication match each other. And although that sounds really simple, it’s actually a real advancement because previously it was all handwritten. So, we’ve seen a real benefit in terms of that medication administration”. From speaking with Sarah previously, I know several potentially hazardous events have already been prevented through this approach
• “From a clinician’s perspective, they can access the patient record wherever they are. So, if they’re on call and they are at home, they can now access the patient record and see the observations, see the clinical documentation, see the test results, in real time, in one place. Previously they would have had to do that over the phone, and speak to numerous different people on some occasions, and actually come into the hospital if they needed to, so they can do that from home. That’s an on call issue, but they could be on a different site; they might be working in a different area. But somebody’s asking for some support and advice for a patient on another site. They have [the EPR] deployed on their mobile phones or their tablets and they can easily access”
• “[The EPR] also has a function called Secure Chat. What we’re seeing with that is clinicians being able to communicate from one single place, to ask for support, advice within real time. The clinicians will get an automatic alert and they can respond. Previously you might have had to bleep somebody, try ringing several different departments to get a hold of somebody. But they’re also set up in group communications as needed, so in those specific circumstances you’re not relying on one person, you’re waiting for a [member of a] group”
• “When a patient comes for an appointment, there’s always a letter that’s written from the doctor to the patient’s GP. Our turn-around time for that is now 7 days. It used to be a number of weeks on occasions before letters could be communicated”
• “Similarly with patients being discharged from hospital that [letter] is also generated from the system and the GP receives that within 24 hours. So, we’ve seen these real benefits around taking out the time delay, taking out the waste along many of our pathways”
• “We’re able to get patients to complete patient questionnaires before they attend for their appointments. Before their operation, they can complete their pre-op information which saves time for them and for the clinical teams when they attend”

“We’ve got a widespread set of areas that have really improved, significantly different. That standardisation is developing across those 10 sites. We know that by reducing variation you improve outcome and efficiency, and we’re starting to see the benefit of that”.

“We’re continuing to identify where we can do more and optimise. As I mentioned earlier, we’re kind of in transition from stabilising, which took 12 months, to optimising. So that’s what it can do in its basic form, what can we actually deliver with it? And taking the learnings from across America and Europe, and those learnings can be quite significant”.

It is clear that the EPR programme has already delivered some amazing benefits across all aspects of the organisation. But it must be so exciting when looking to the future. Hive has provided a bedrock, a foundation from which to build and the are numerous opportunities moving forwards.

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What Advice Would You Give for Other Transformation Projects?

As somebody who has lived and breathed such an amazing, complex, and successful transformation project, I wanted to understand from Sarah what advice she would give to others that are considering similar programmes of work.

“Engage with your stakeholders, whoever they are, whether it be your customers, your staff, your external partners, commercial partners, whoever that may be within your world. Engage with them from the earliest opportunity so that everyone’s really clear on why we’re doing it. What is the objective? And actually, what your timelines are and what you need from them. So, what is the expectation, and manage that expectation for all of those key stakeholders”.

“Be as transparent as possible. We found it’s OK to say you don’t know. Actually, you are doing something so significant that some questions you can’t answer. So what will that mean in four months’ time? What does that mean for this group of staff? Just being really honest and being able to say we don’t know at the moment, but we want to work with you to work that out, and keep you engaged in the conversation. Something as significant as a change like this, for some people, that means their job may disappear. But actually, there are other areas of work that we need support with, so it’s keeping people, those key stakeholders, as engaged as possible. And also, don’t be surprised that people are really resilient. If you keep them engaged, and you keep them connected in, it’s amazing what people can do”.

“From a training perspective, make sure you think about who the best people are to train. The system trainers are great in knowing a system, and which button to press at what point? But actually, in health, and it will be appropriate in other industries, that’s just a process. There’s usually a wider educational piece that’s needed. Our best trainers were peer-to-peer, so our nurses training our nurses, our doctors training our doctors, with some technological support”.

“Learn from other places. If other places have done it, speak to them, talk to them, understand what their biggest challenges were, and take their advice. But make it appropriate for your area, organisation, or sector”.

“As an organisation the decision was taken to put a full-time board executive as the programme SRO [Senior Responsible Officer]. What that signalled to the organisation is a how important this programme of work is. But also, we had executive oversight for supporting with escalations, mitigations, risk management, decision making. Without that as the oversight, it would have had a very different feel, which is quite a soft description. But actually, having that executive board level leadership was essential. It was Julia Bridgewater who was our exec SRO. She did walk around in a bee costume for some of the pre-engagement, and also post go live!!”. For anybody that doesn’t know, the bee is one of the symbols of the City of Manchester, which is also why the programme was named Hive

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Conclusion

How would you feel about delivering the Hive programme? I know I’ve said a few times that it is the most complex project I’ve heard of, and I stand by that. But, Sarah has provided some extremely valuable insights into how to make such a transformation a success – and it clearly has been at Manchester University NHS Foundation Trust. I can’t wait to hear how things develop moving forwards with such a solid foundation to build upon.

Just recapping on the key insights and recommendations from Sarah:

• Create a brand – to increase engagement, move away from a programme being technology delivery. The technology is there to support, not to drive
• Engage with your stakeholders – engage with all of them as early as possible. If people are engaged and know what needs to happen and by when, they will help to deliver
• Sponsorship at the right level – set a clear intention for the programme with dedicated decision making, support, and influence at the right level in the organisation
• Make decisions – not making decisions is the downfall of many organisations. Get the right people together to make the best decisions you can, and then empower them to make those decisions
• Communicate – you can never overcommunicate! Use the right channels for the people you are communicating with, and talk about their issues, especially as the post go-live adrenaline begins wears to off
• Be as transparent as possible – if people know what is happening, they will be engaged. If they can see the best decisions being made, they will be engaged. If they receive regular communications they will be engaged
• It is OK to say you don’t know – this shows you are human, the work is complex, and you are being honest and open. But by asking for help and support in return, and providing regular updates, people will remain engaged
• Start data and integration work early – these can be extremely time consuming endeavours and you can’t rush them
• Create a training plan – understand who your change agents are and remember peer-to-peer training caries more relevant weight as things are explained in real terms
• Prepare for go-live – ‘By failing to prepare, you are preparing to fail’ – Benjamin Franklin
• Manage the go-live – understand how you are going to triage incidents, establish communication channels, and provide support. Sarah’s command and control structure is a great example with quick resolution of issues and escalation, supported with floor walkers and super users
• Remember the human aspect – as Sarah mentioned, “people are really resilient”. This is so true! If they are engaged and given the chance people will smash through walls to make positive change happen
• If all else fails, dress like a bee 😊. Bringing some humour to a stressful environment, making things more light-hearted can have a massive impact. Plus, it makes you clearly available for people to stop you and ask you questions or for support

Let us know in the comments below if you have had similar transformation programme experiences, and what has worked well for you when delivering complex change.

CHECKOUT THE PODCASTS FOR THIS ARTICLE

Part 3/3 with Sarah McGovern, talking through her recommendations after running one of the most complex transformation programmes we have heard about, Manchester University NHS Foundation Trust’s replacing  Electronic Patient Record system