More time for patient care in mental health service
“What other systems have you come across that delivered exactly what they said to over 800 staff in 12 months flat?” Nick Hodson, Head of Service Improvement, Derbyshire Mental Health Trust
One in four of us will experience mental health problems at some time in our lives. Organisations such as Derbyshire Mental Health Services NHS Trust are therefore critical in helping to improve mental health and wellbeing. The Trust provides a wide range of services to a Derbyshire population of nearly a million people living in a mixed rural and urban catchment area of a thousand square miles - with some marked areas of deprivation.
The quality of these services is assessed by the Quality Commission as excellent. The challenge, however, in continuing to maintain this standard in the new world of Foundation Trusts, world class commissioning and payment by results (PBR) lies in being able to collect clinical activity data in a timely, comprehensive and accurate way. The Trust has continued to seek solutions to improve the amount and quality of its data capture thereby ensuring that they are able to report data to commissioners accurately and in a timely way.
“Clinicians often struggled to enter activity data,” says Nick Hodson, Head of Service Improvement for the Trust. “Having written out diary records during patient visits they had to drive back to base, find a PC, boot it up, pray that it worked, open the application if it was running, find the patient, fill out fields to show they’d been to see them ... and often in return get another report to say how bad the data was.”
A series of technological false dawns and restricted access to hardware had led the clinical workforce to see technology as the problem, rather than as a solution which could ultimately help to improve patient care - the key deliverable for them.
It therefore became increasingly apparent that a fundamentally different approach was needed – one that would enable clinicians to enter their activity data with less hindrance, less effort, and maximum reliability. At the same time, says Nick Hodson, the consequences of failure were very high. “On the horizon of change, approaching like a maelstrom, were activity-based contracting and ultimately PBR. If we failed there would be no shelter from the storm!”
The breakthrough came when a small group from the Trust were invited to an “art of the possible” meeting hosted by BT, where a number of technologies were showcased under the banner of “agile working”.
“When was the last time,” asks Nick Hodson, “when you saw something that instantly appeared to be an answer to a massive challenge ... but seemed so simple that you instinctively felt it must be too good to be true? Well, that was our experience when we first saw the Destiny digital pen, which is based on Anoto technology, in action. We were invited to write with the pen on a piece of paper, which has a special do pattern printed on it and tick a “send” box – at which point the information was sent via a mobile phone to a server, and onward to an application on a laptop ... all in seconds before our very eyes. We could all instantly see how our staff could do exactly the same thing out in the field, sending their clinical activity data straight into our information systems. It was as simple as that.”
The data collection sheet was designed by a ten-strong project team. It consisted mainly of users with the support of in-house Information Technology and Information Management teams as well as Destiny and BT personnel. This part of the project was critical in getting buy-in and ownership, in ensuring that the data set was fully in-line with what was already being collected, and in eliminating potential data entry errors. This required detailed programming both by Destiny and by the Trust on their Care Notes system.
The issues of confidentiality and security were also carefully reviewed. “We spent time assuring ourselves,” says Nick Hodson, “that the process was more secure than previous arrangements, in that workers would be transporting even less identifiable information. We validated our thinking through our information guardians and our governance arrangements.”
Encrypted data is sent from the digital pen to a mobile phone via Bluetooth where it’s again encrypted and sent via the Internet to Destiny’s secure mirrored servers. This in turn sends converted data (in the form of a graphical pdf of the original handwritten form and an xml data file) via encrypted email directly to a Lotus Notes application in an automatically managed inbox at the Trust, where it updates the Care Notes system through an ID matching process. Any incorrect entries are sent to a holding area where they’re reviewed and managed.
Clinicians need little training as the solution replicates existing practices, and simply involves using a different pen.
The next important step for the Trust was to carry out a three month pilot with ninety staff across three Community Mental Health Teams. These were an adult CMHT delivering care in a rural area (whose activity recording was very patchy), an Older People’s CMHT delivering care in a challenging socially deprived area (whose recording was renowned as accurate and consistent month on month), and a Crisis Resolution and Home Treatment team with the challenges of 24 hour care and the associated intensity and risks (whose activity recording appeared to be presenting them with a series of problems relating to timeliness and accuracy).
The results from the pilot were impressive, and very revealing. In the area of improving the quantity of data collected, the Adult CMHT increased their recorded activity by 80%. In the area of timeliness they improved to in excess of 80% of data being entered the same day, with a further 10% within a week.
Similar timeliness results were achieved by the Crisis Team - a huge improvement. In the area of data quantity they improved by 25%.
The most surprising result was that although the quantity of data entered by the Older People team had always been excellent, the massive degree of lateness had never really been visible before, as it had been masked by flex and freeze activity reports that were at best two months retrospective this has now been massively improved and is processed the same day.
Based on this highly successful proof of concept, the new system was rolled out to a further 350 staff in 21 teams in a further twelve week period. Similar improvements were made depending on each team’s baseline position.
In the area of quality the data entering the system is by design 100% clean, thanks to administrators who are able to “auto-correct” errors by users in mandatory fields as part of a pre-validation process.
Since clinicians no longer need to return to base to enter their data, they’re able to save significant amounts of time, which allows us to ensure the quality of our service delivery, reduce travel and concentrate on improving patient care. The information sent from the digital pen is also contemporaneous to the event being recorded. As well as improving timeliness, this makes for more accurate and meaningful reporting at an individual, team, service, business unit and Trust level, and supports the demonstration of target attainment and capacity planning.
“Users can rightly see that we’ve invested in a technology which works for them as well as the organisation,” says Nick Hodson. “It’s stimulated their appetite for proposing additional uses, and has helped to restore their confidence in technology - easing the pathway to developing a more efficient and flexible workforce.”
The next step is to roll out the system to a further 300 staff in the north of Derbyshire. The challenge here is that data in this area was previously entered by data entry clerks onto NCRS (National Care Record System) as part of the early adoption of Lorenzo – and that the operating system wouldn’t support data collection via a third party device.
Working with Destiny and BT, the Trust found a solution through Blue Prism – an “operational agility” software company who successfully resolved the issue by providing an interface between the digital pen and IPM.
“We’re delighted with the adoption of digital pen technology,” says Nick Hodson. “It’s taken us a big step further towards payment by results, and becoming a Foundation Trust. Not surprisingly we’re getting lots of enquiries from other trusts. After all, what other systems have you come across that delivered exactly what they said to over 800 staff in 12 months flat?”
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