#NHSChangeDay pledge – ward dashboards and dictation


NHS+Change+Day_logo_calendar_png_5_____On NHS Change Day I committed to make more effort to visit front-line services that were using technology with an increased effort to understand the issues they face and to learn from them.

In a national role it is easy to feel disconnected from the front-line.  I already work an occasional shift on a ward, which certainly keeps me grounded, but in my role I am expected to have a really wide understanding of things related to informatics and in truth it’s a real challenge; not only do you have to keep up with the technology, which is going so fast, but also a wide understanding of how care is delivered.  I understand that I will never know everything about all of this and I never offer views about things I genuinely don’t understand, preferring instead to try to network people together who do know, but it is nevertheless essential that I have a broad understanding.  My visits are an attempt to make sure I increase my awareness and am genuinely doing my best to represent the profession in the wide ranging discussions I get involved in – I like to evidence my conversations where I can.

technology future

I arranged a visit to Northumberland Tyne and Wear NHS Foundation Trust.   angel of the northI had a great day – everywhere I have ever been to visit has always made me really welcome and North Eastern folk are renowned for their friendliness and hospitality.  I had to drive for 2 ¼ hours to reach the site but this was eased a little buy having to drive past the Angel of the North which I love.

There were two things they were showing me:

The first was the ward dashboard.  This is a great project.  The word dashboard implies something that shows performance against some targets, theirs is so much more than that.  They have moved the concept on a step and the dashboard is more of a knowledge centre.  They do have a screen that shows the key targets for them where they are using the Royal College of Psychiatrists ‘Accreditation for In-patient Mental Health Services’ (AIMS). These standards are a key quality improvement driver for them – you can read more about AIMS here:

http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/psychiatricwards/aims.aspx

The interesting thing for me about what they have done is they have gone beyond using the dashboard as just displaying performance and turned it into a knowledge centre.  There are many resources that staff can use that can help them to do the best quality work; evidence based assessment scales, forms, pathways – in fact a really useful resource for staff arranged in a central location that is kept up to date and fresh – I really liked it.

The second part of my visit was fascinating; first of all I want to tell you a story:

Imagine you are a community psychiatric nurse and you have just visited a psychotic patient.  They have complex needs and you leave their home and you know need to document the visit, it’s Friday and if anything happens over the weekend you want your notes to be available in the electronic system.  You pull your small car around the corner into a safe parking place and pull out your laptop.  You know you can connect but it’s a bit of a struggle, you have to turn around in your seat to open the lid of the laptop.  It takes your around 45 minutes to key in the information and you sigh with relief, stretch out and close the laptop down when you are finished.

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This is a real situation for many mobile staff.  Access to electronic systems has improved, so has equipment but inputting information into most devices in a car is a real challenge.

In NTW they were finding that clinical staff were regularly spending significant portions of their working day typing clinical documentation, in fact they were often spending longer documenting than actually seeing the patient.  Nurses are not always the best typists and the time taken to type into records can be laborious and was creating inefficiencies in the way they used their time.

The trust came up with an innovative way to try to tackle this problem – dictation – and it works! So the nurse now has a Blackberry into which she/he dictates a summary of the visit.  The recording is sent immediately to a dictation team who enter the information in draft form into the record.  By the time the nurse gets back to her home or base all she/he has to do is to check and authorise the entry.  It takes around 8 minutes for a long entry but many take less.  The results are impressive.

I spoke to a fantastic CPN who showed me how she worked.  She told me that it is difficult at first, dictation of records is not a skill nurses are taught and it feels strange but they developed some prompt sheets and a way of working that means they soon gain confidence.  Hannah, the CPN, had managed to save so much of her time that she had taken on extra duties assessing referrals to reduce waiting times – she was a really impressive nurse!

These images show an average day before and after dictation (the red is admin time, green patient time and yellow travel) for another CPN.  Its sampled days and not averaged but still gives an impressive perspective:

before dictationafter dictation

This is just a pilot for NTW, they have more work to do to see if they can make this work efficiently and at scale, but it really got me thinking.  I have done some web-surfing and nearly all of the work that has been done in dictation is for doctors in acute settings and concerns off-shoring of dictation but it could really make a difference for lots of community nurses too.  It demands that we develop new skills and ways of working but the early results in NTW are very impressive and worth exploration.

My visit achieved exactly what I had hoped for – my thinking has changed and I have new ambitions for the way electronic records could operate.  Thank you to all the staff at NTW NHS Foundation Trust who generously gave up their time for me – I am very grateful.

Is digital enough?


Twitter is fantastic as a place to have great conversations that wouldn’t be possible without this digital space – I love it – but again today I had another fantastic Tweetup, that is a face-to-face meeting with someone I first met on Twitter. It seems to me that as my twitter relationships evolve I instinctively want to make the effort to meet the person face-to-face. For me, it seems that for the required depth of some of the relationships, digital just isn’t enough. So what happened today was a little bit of face-to-face magic with @smclrk where I learnt so much and started to form a relationship that I hope will endure, that Twitter conversations alone would never have achieved.

This led me to think about some of the debates about using technology to deliver care – is digital enough? Many readers of this blog are likely to have read my earlier blog ‘To Whom it May Concern’ – it’s one of my most popular postings – and are likely to note that I seem to be advocating less face-to-face and more digital. Similarly Roy Lilley’s (@roylilley) blog for the KingsFund ‘It’s crept up on us’ is saying similar things; we need to recognise that in the world we know today surely technology has a greater role and place. I whole heartedly agree but I find the debates that this generates distracting and extremely frustrating.

The trouble is it sometimes feels like we are looking for a silver bullet, or a single direct approach or solution to the complex challenges we face in delivering care in a changing economic and societal landscape – in truth there is no one solution. complicatedSo why then do commentators persist in saying you can never replace face-to-face with technical solutions, implying that advocates of technology are saying this is the single way? I have never heard any advocate of new ways of using technology or innovation say that this is the case! What they do say is that for some processes (ordering repeat prescriptions for example) or transactions (a query about diabetes control from an experienced patient via email) technology can play a part.

When I went to work at NHS Direct in 1999 I remember being told by other nurses that you can’t care for patients over the telephone. 9184840_sI think this debate is past us now with lots of care being delivered using the telephone; but this is also not without its controversy, if I ever tweet or talk about my personal desire for telephone consultations someone will comment or question to say that I ‘don’t understand’ and that we should always use face-to-face and my heart sinks. I have never said or suggested that we could completely replace face-to-face care. As a person with a long term condition I can say for me that technology can have a role that will improve the quality of my life and (maybe) reduce the cost burden of my multiple hospital visits but equally I need to see my Diabetes Specialist Nurse sometimes for a different sort of conversation that cant be achieved on the phone or via email.

So, is digital enough? I say that it isn’t, and never will be, but it must have a role. Like my experience on Twitter some remote digital relationships are enough but for some, face-to-face is the way to go. My suspicion is that digital will have an increasing role in healthcare but it will never replace the dialogue that we have as human beings who occupy the same room. My plea is can we be balanced in our approach to adoption of new approaches to delivering services using new technologies that may improve the quality of life for some people?