Putting the standard into practice

Transfers of care
1.
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About this toolkit

2.
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Getting to grips with the standard

3.
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Getting people on board

4.
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Taking stock and planning

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Putting the standard into practice

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Shared resources and learning

Putting the standard into practice

Having agreed your roadmap with stakeholders, you can now begin making the changes and putting the standard into practice, managing the impact on people and processes as well as the technology.

To implement the standard, your completed Taking Stock analysis and Getting People on Board work will have assessed your current situation and identified what improvements you aim to deliver and when, positioning your starting point for change.

 

Develop a detailed timetable

Based on your high-level roadmap, develop a detailed timetable for change with dates and responsibilities clearly identified. This will signal to stakeholders when the change programme will begin, how long it will take and prepare them to fulfil their role in making it happen.

Consider the following when pulling together your timetable:

Phases
A phased approach to implementation is often helpful to manage systems and stakeholders. It also reduces the risk of issues accumulating, as you can address them at each phase.

Piloting
A small-scale trial at the start of a project can help to refine your plan and test systems and requirements.

Stakeholder management
Share your timetable for change as early as you can and provide regular updates to stakeholders, so they are engaged in whether progress is being made with implementation and how they can contribute, as needed.

Plan and procure system changes

The outputs from your analytical activities will support the development of a requirements specification needed for your IT team or system supplier. If a re procurement of one or more systems is needed, this specification will be submitted as part of an invitation to tender.

  • If you have a bespoke system, it needs to be updated to comply with the PRSB eDischarge Summary Standard. 
  • If your system is purchased off the shelf, you are responsible as a provider to check that it complies with the standard. Look for the PRSB Quality Mark.
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Procure the system changes needed ensuring that systems will be delivered that are conformant with the standard. See NHS England procurement guidance.

diabetes monitor device

Agree how the team will be involved in testing the software to ensure it is conformant and meets local requirements.

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Technical message standards can be found in the NHSE API catalogue. New APIs will be required for sharing data generated by the person as part of their self-management with electronic records.

The PRSB Standards Partnership Scheme was established to support providers and suppliers in demonstrating compliance with PRSB standards. Further information on requirements can be found in the information standards notice (ISN) and PRSB standards conformance guide. 

Implement the standard

To implement the information model and associated business rules of the eDischarge Summary Standard, it must be incorporated into your clinical systems.

 

IMPLEMENTATION CHECKLIST

Make sure you have a data model for your application.

Map this model to the PRSB eDischarge Summary Standard.

Identify and map any reusable data components e.g. diagnoses, procedures, allergies to the standard.

Identify and develop the missing components into the data model.

For interoperability, identify the APIs supported by your application and map these to the PRSB standard.

Implementing the standard in your system will contribute to the development of your applications, so that they can record, display and share data that is human and machine readable, and cross-organisation usable.

Human readable: data that is structured to make it more useful, readable, and unambiguous for end users i.e. the narrative for the patient. Human readability typically refers to the narratives shown to an end-user/clinician.

Machine readable: data that can be sent out easier for computers to parse, sort, index, etc. Machine readability refers to the discrete elements of a record or the metadata sent with documents to be reconciled into a patient’s record.

Cross-organisation usable: data that is sent in a way that is easy for the receiving party to accurately interpret and derive value from.

Discharge summary design

Whilst the eDischarge Summary Standard itself does not specify the design or layout of the final discharge summary output, it is good practice to incorporate the requirements of the standard into a user-centred design.

Taking a whole system approach, work with your intended recipients so that the layout is structured in a way that is most useful to them. This will ensure a consistent user experience, reduce the time taken to process the data and also reduce the risk of errors. 

Medications

Medications

  • List medications alphabetically.
  • Map medications to dm+d.
  • Include all TTOs.
  • Clearly indicate which medications are new, continued repeats or discontinued.
  • Changes to medications must include reason.
  • Clearly indicate if there are no changes.
  • Include medications administered during hospital stay.
Doctor and patient

Actions and care plans

  • Detail a clear plan of care for the patient.
  • All actions for the specified professional should be made clear.
  • Include actions for hospital staff e.g. checking test results.
  • Primary care should not be actioned to follow up on tests requested by the hospital.
  • Include all referrals to other services and the required timeframe for response

Diagnoses and procedures

  • All confirmed and working diagnoses must be included.
  • All procedures carried out in hospital must be included.
  • Any planned procedures must be included.
  • All diagnoses and procedures must be unambiguous and SNOMED CT coded.

SNOMED CT

To achieve a single reliable source of data for multiple purposes, record keeping and data definitions must be standardised including the implementation of SNOMED CT on all clinical systems.

Acute hospital trusts should aim to have all relevant systems using SNOMED CT to record structured data at the point of care. 

Benefits to the discharge process of using SNOMED CT include:

The discharge summary is immediately populated with structured and coded data.

Clinical decision and resource planning is well supported by clear, consistent, unambiguous data.

Improves systems interoperability, data sharing and data security.

Required SNOMED CT Knowledge

The UK edition of SNOMED CT member national release centre (NRC) is managed by NHS England and more information can be found on their website.

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Download a one-page guide, outlining the necessary data, skills required and potential training needed. Using clinical terminology.

Hospital discharge process

In addition to the implementation of standard, improvements to the operational discharge process and the creation and processing of discharge summaries will significantly contribute to the benefits.  

Here is a table of suggested changes to the discharge process that could be considered in the context of your local needs and priorities. This will be dependent on your workforce and clinical record systems in place.

Hospital discharge

Download: Effective discharge summaries table (PDF)

Piloting

We recommend piloting a small-scale trial; implementing the information standard for a small number of users or in a small locality. After these users have been trained, the project team can make charts of the processes involved – these charts will form the basis for training all users to access and utilise the information standard.

There are several advantages to running a pilot:

Reduces the risk of a full-scale implementation as adjustments and modifications can be made as a result of the pilot.

Improves processes through evaluation of the process charts produced during the pilot.

Develops training materials through conversations with users from the pilot who can share their learnings.

Clinical safety

Manufacturers and health and care organisations are both required to comply with standards in clinical risk management, mandated in England and adopted in Scotland and Wales. 

The standards describe a coordinated set of activities to analyse and mitigate clinical risk in health IT systems.

There are two clinical risk management standards:

  • DCB0129 which includes the standard specification and implementation guidance for manufacturers
  • DCB0160 which includes the standard specification and implementation guidance for healthcare organisations.

 

PRSB use DCB0129 guidance and all PRSB standards include a safety case and a hazard log. Your system suppliers will also need to comply with the requirements of DCB0129 and you should request evidence of this from them.

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Why use a safety case and hazard log?

The purpose of the safety case and hazard log is to identify the hazards which could cause a person harm by using the standard, along with how that hazard can be mitigated. There are different types of mitigation – through system design, testing, user training or business control processes.

  • Develop your own safety case and hazard log, using NHS DCB0129 guidance.
  • Have registered clinical safety officers to ensure the systems implemented are safe for clinical care.
  • Run risk assessments to determine the likelihood and consequence of a risk happening. 

 

As part of ongoing clinical risk management, it is recommended that regular clinical risk assessments are undertaken. This can be done using a recognised tool e.g. SWIFT or BOW TIE.

Resources

Monitor, measure, adjust

Once you have implemented the eDischarge Summary Standard, you’ll want to measure the success of your project.

Consider establishing a reporting mechanism, such as a discharge metrics dashboard, to monitor, audit and evaluate the ongoing performance of all your discharge pathways.  

  • Are the expected benefits being achieved?
    If not why not and how could this be improved?
  • What has been learnt that would improve the process and outcomes?
 

Download and use the dashboard metrics dashboard.

  • The dashboard must be owned by the system as a whole rather than by one particular organisation.
  • The dashboard would display data extracted from your secondary and primary care systems for advanced analysis, reporting and visualisations of the transfers of care.

Download: Discharge metrics dashboard

Make use of your skilled data analysts / BI teams to design and operate the dashboard.

Work with them to define the queries required to interrogate your clinical systems, match and blend and psuedonymise the data, and present that data in a usable and appealing way.

Start small; agree a dataset that is robustly and repeatedly tested so that it can be trusted. In time, the dashboard can be developed to give a system-wide view of the state of patient flow, capacity and demand.

You should expect to go through iterations to get your implementation right over time. This gives you a chance to review data on the effectiveness of the changes.

Make sure that Data Protection and Information Governance requirements are taken into account.

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Introduction
Develop a detailed timetable
Plan and procure system changes
Implement the standard
SNOMED CT
Hospital discharge process
Piloting
Clinical safety
Monitor, measure and adjust

PRSB Standards Explained

Why we need standards to record our health and care information in a consistent way so that it can be made available whenever it is needed.

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Making change happen

Transformation programmes need clear goals, the right leadership and engaged staff and stakeholders. Get started by reading our information on transformational change.

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.