Mark Axler of MAON and Andy Evans, head of ICT at the East Midlands Ambulance Service, discuss the contribution systems thinking has made to the National Programme for IT in EMAS’ Trust.
If anyone could have predicted the profound change the intelligent application of technology could have on healthcare and clinical outcomes we wouldn’t have needed a national programme for IT, which at its heart was the improvement of patient centred care and the reduction of clinical risk.
Launched in 2002, the National Programme for IT in the NHS was an ambitious £11.4bn investment designed to reform how the NHS in England uses information to improve services and patient care.
The programme itself, the technologies and systems have been thoroughly examined elsewhere. Yet, few practitioners have chronicled the contribution of systems thinking to the National Programme, or reviewed the initiative from a systems thinking perspective.
The East Midlands Ambulance Service first introduced IT systems within its own Trust. Later, it developed the means of interacting with other NHS Trusts to achieve systemic change.
The NHS has long recognised the importance of systems thinking. Outside, the NHS may often be regarded as a whole system, but it is actually comprised of hundreds of separately accountable organisations. So, it is more akin to a complex adaptive system than a whole system.
Traditionally, Ambulance Services have been funded to operate a transportation system that directs patients towards hospitals, which are funded to admit them. The system operates when it moves patients from point to point.
The EMAS NHS Trust serves 4.8 million people within the 6,425 square miles of Derbyshire, Leicestershire, Rutland, Lincolnshire, Northamptonshire and Nottinghamshire. Last year, it responded to over 670,000 emergency 999 calls and made over one million patient transport journeys from 76 bases. The Trust employs over 3,200 people and connectspatients with 11 Primary Care Trusts (PCT) in the East Midlands and 2 PCTs in Yorkshire.
Figure 1 broadly illustrates the system EMAS operates.
It’s generally assumed that patient care starts in a hospital because traditionally patient care started in hospitals. Actually it starts with the Ambulance Service: from an operations management viewpoint, Ambulance Trusts treat and transport patients, and only then a hospital admits them.
WHAT EMAS WANTED TO ACHIEVE
EMAS’ aim was to improve the clinical handover of patients. It agreed to achieve this objective by replacing the paper record form, which it completed for each patient, with an electronic patient record forms (EPRF) on laptop computers.
The system was piloted in South Derbyshire, which achieved “Initial Go Live” because one user was trained on one EPRF laptop and one EPRF laptop was installed into one ambulance, deployed, and connectivity was confirmed by one user logging into the live environment.
The Trust trained 200 staff and deployed 40 EPRF laptops. Yet it felt like it had just implemented technology: if that was as much as the programme would achieve, this would become an expensive way of counting beans. So, what next?
It invited MAON to review its programmes and assist it to implement enablers and achieve more from future deployments than just implemented technology.
MAON advised it that its commitment to implementing technology change, alone, was unlikely to prevent people from going to hospitals. To succeed, change capability and capacity needed to be developed, technology needed to be regarded as an enabler and the strategic focus needed to centre on the patient journey. External involvement of locations receiving patients would be critical to achieve the benefits this programme warranted. This would require engagement and learning.
EMAS accepted their advice. The upshot led to reshaping the programme within a strategic change framework and revising the strategy and logistical roll-out plan. Programme governance was refocused externally because control mechanisms were internally focused. And an engagement strategy was built to nurture the development of relationships with staff, partners and patients.
Systemic change takes time to convey to people and organisations which are hardwired to think otherwise. To receiving locations EMAS said that ambulances stacked outside a hospital with patient numbers that exceeded capacity is avoidable, so that they would work with them to solve mutual problems and together they could rip up the old world and drive whole system change on an industrial scale.
To its own staff EMAS said transporting patients to hospital was a mechanical choice that arose from the way the system was established and still operated. Failure isn’t keeping people out of hospital. New technology enabled the Trust to make clinical choices with patients. They helped EMAS unshackle its system and change how it works with other organisations and patients.
Figure 3 broadly illustrates the patient’s journey from a systems perspective.
This journey starts in the community and ends with ward treatment. EMAS’ role starts with the patient and endswith clinical handover. So to improve care, it asked how it could improve the system of patient handover at Emergency Departments and how it could improve ambulance turnaround times to serve more patients in the least time.
Reformatting the patient care system entailed changing softer systems. EMAS started by asking itself and partners: “What do we need to change about ourselves and how we work together?” Conscious that change capability was limited to a few dispersed and heavily committed staff, MAON designed and packaged the Trust’s learning and theirs into a Business Change & Engagement Toolkit.
It offered staff the non-prescriptive means to better change from first principles. It became the platform upon which the Trust would build capacity and change capability.
In 2010, it adopted the toolkit as the standard approach to change.
On account of the lessons learne d from piloting and the review MAON helped EMAS develop engagement plans and revise programme governance, planning and assurance arrangements to facilitate integrative governance and joint working between EMAS and receiving locations under the National Programme for IT Local Ownership Programme.
Having secured programme board commitment to the idea of joint governance, in August 2009 the Trust’s chief executive invited other Trusts’ chief executives to nominate representatives to participate in a joint planning meeting. The meeting would confirm the feasibility of EMAS’ proposals, whether other Trusts would work with it, how, and what their expectations were.
Initially, no one outside EMAS attended the planning meeting. So the Trust adopted a more vigorous follow-up approach, saying that by the end of the first workshop participants would have:
- Discussed and agreed the context for the business change and engagement;
- Conducted high level process mapping of the patient journey and discussed changes;
- Defined the benefits, jointly, and the need for changing the approach to engagement;
- Agreed to identify the engagement governance arrangements in their Trust by Workshop 2.
The interactions between the various parties involved in patient care and the patients themselves are at the interfaces of care.
Workshop 1 participants agreed that improving the patient journey rested on EMAS and receiving locations working together, improving handover, and exploiting enabling technology collaboratively.
In the second workshop attention focused on the handover points, in particular the relationship between partners and patient and system outcomes. Figure 4 illustrates systemic pressure points.
- For EMAS turnaround time at receiving location was a critical performance parameter. Working with receiving location offered the prospect of optimising resource at a time when emergency journeys were forecast to increase at an annual rate of 3%.
- For receiving locations minimising the four hour waiting target limit on patient admissions was critical. Since patient admissions are rising at an annual rate of 11%, there is considerable pressure on receiving locations to identify the means to reduce pressure on their services.
- Implementing technology into EMAS and receiving locations without commitment and action to change would exacerbate problems. Collaborative working was seen as the way to resolve mutual dilemmas and enable benefits for patients.
The final workshop element specified processes to support local ownership of the engagement strategy in the second and subsequent waves. A recommendation towards the end of the workshop led EMAS to develop a form of interorganisational agreement to change, which aligned with the revised programme governance. The agreement was formatted as a Project Initiation Document (PID). Figure 5 illustrates the way in which each PID related to the revised governance arrangements.
The Joint PID became the foundation for the programme board to sanction joint work, monitor progress, and review deliverables periodically and on completion of a project wave. Operationally, it became the tool the internally appointed clinical change manager used to manage implementation across the system day-to-day, and report to the programme management group. From a receiving location perspective, it supported colleagues in other Trusts to monitor progress and benefits to themselves and patient care, and engage in partnership working and improvements.
WHAT’S BEEN ACHIEVED?
The programme was transformed from one which was internally led by technology to one which was systemically and clinically focused and enabled by technology across the East Midlands.
A systemic approach to patient centred care through clinical practices was embedded. This approach continues to enable partners to stem patients flow to hospital, in accordance with the business case, and simultaneously reduce clinical risk.
The system of care now enables EMAS to perform life-saving diagnostic assessment sooner and commence treatment. Patients no longer have to wait nor expect advanced care to start in a hospital because well-trained paramedics are able to carry out more treatments, on location, on occasion, with support from hospital clinicians. Hospitals can now expect more care to start before a patient arrives. Together, EMAS and hospitals can improve the management of demand because now they can exchange advance notice of patient flows across the system.
- Achieving beneficial outcomes for patients requires Trusts to work as a whole system and on an inter-organisational basis across boundaries and interfaces.
- Whole system change should be framed within joint governance arrangements. Joint governance recognises that systemic improvement is reliant on all parties collaborating. Therefore a suitable engagement framework must be created to support joint oversight and joint working.
- Whole system working evolves and emerges through experience. Shared objectives and collaborative structures can be created and shaped with partners when there is the will to do so.
This story of change is a credit to patients, receiving locations and MAON, which is why we’re telling it together. This is the story of a £4m IT programme going right. It started in EMAS, spread to nine NHS Trusts, which literally serve millions of patients in need.
Altogether, we have achieved more than just implementing IT.
Patient care will be better tomorrow than it is today. And still, we think it can be even better, because now we know how to build bridges, and cross gaps. We also know that although we’ve learned a lot, there will be many more things to learn in the future, for change is constant. So, as new challenges unravel and we evolve cooperative solutions together we will incorporate them into care practices and, above all, remain ready for change.