Centralisation of Trust Policies

Project received a commendation from theSally Hernando Awards 2011-2012 for

Organisational Initiative for good/best practice(SHALL, 2011)

Lynn Allan MSc MCLIPE-Resources Librarian

Contents

• Background to Project

• A working solution

• Current issues and future challenges

Background• Issues with Maternity & Neonatal

Care – CQC (Care Quality Commission) and

Monitor involved with investigating SUIs (serious untoward incidences) in 2009/2010 (KPMG, 2012, p4)

– Monitor continued to oversee Trust and open further investigation in November 2011(Monitor, 2011)

Monitor finds “governance processes and systems are inadequate and are below standard” (PriceWaterhouseCooper, 2012, p5)

Key Drivers

• NHSLA (Litigation Authority) Risk Management Standards

– at Level 2 - demonstrate procedures to respond to NICE guidance

– for Level 3 – monitoring compliance

• Trust Risk Register – failure to locate information on the intranet

Policies on the intranet

So many different places to look!

They are such a mess!

But how do I find them?

Which version is the correct one?

I’m getting lost here!

NHS not the only organisation that has problems with the intranet:

More than half (52%) of respondents say they cannot find the information they are seeking using their own organization’s enterprise search facility within what most define as an acceptable amount of time (Mindmeter, 2011)

Trust attitude

http://openclipart.org

The intranet works fineIs there a problem?

We don’t need a new system You just need to know the

right place to look

What’s really needed

- A single document management system to house all Trust policies

- A single taxonomy required - A single team to manage revision

control, including prompting editors- Strict version control required

How did library get involved?

• Library Manager attended Integrated Risk sub-committee meeting

• E-Resources Librarian also attended meeting involving IT, Clinical Audit and Marketing.

• Senior Library Assistant key to cataloguing all policies consistently

A working solution

Have you heard of the

Library Management System (LMS) Heritage?

Using in-house:

Trust Savings of £25k

Piloting the project

Pharmacy was the first department to add their policies to Heritage.

Working with Pharmacy a project plan was implemented to identify:

• key information required to add policies

• a working process for adding policies

• length of time required from policies being sent to library staff to them being available on Intranet

• how to adapt Heritage to absorb Trust policies

Process

• Policies sent to library with cover sheet and added to Heritage

• Email confirmation sent to document author when policy added

• From receipt of document to availability on catalogue can take 2 working days, or quicker if necessary

• Revision date approaching – notification email sent to author– If no response from reminder then more pointed

reminder sent out– Still no response? Policy removed from Heritage

Maternity Services were required to:

• organise and update all policies

• Make policies easier to find

In 2011 Monitor announced that UHMBT was in breach of terms to meet Foundation status in regards to Maternity Services.

Maternity Services

Challenges

• Continual approval and support from Senior Management

• Gaining trust from departments• Difficulty getting IT on board Policies continue

to be in two places and staff do not know where to find them

• Intranet editors no longer working for department

• Problems opening policies on some machines• Some users are unhappy with the change• How many policies are there? • Terminology – what do we call Heritage?

Going forward

• Getting continual approval from senior management

• Continue to publicise the new document storage model

• Surgical Division policies are next in line to be added

• Working in partnership with IT to improve the intranet

Thank you for listening

Any Question?

Lynn AllanE-Resources Librarian

University Hospitals of Morecambe Bay NHS Foundation TrustLynn.Allan@mbht.nhs.uk

References

KPMG (2012) Learning and implications from University Hospitals of Morecambe Bay NHS Foundation Trust: London: Monitor http://www.monitor-nhsft.gov.uk/sites/default/files/Morecambe%20Bay%20Report%2026%20June%202012.pdf (Accessed: 2 July 2012)

MindMeter (2011) Mind the search gap Available at: http://www.smartlogic.com/home/knowledge-zone/white-papers/1600-mindmetre-research-report-sponsored-by-smartlogic (Accessed: 19 June 2012)

Monitor (2011) Monitor intervenes at University Hospitals of Morecambe Bay NHS Foundation Trust Available at: http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/latest-press-releases/press-release-archive/2011/monitor-intervene (Accessed: 19 June 2012)

NHS Litigation Authority (2011) NHSLA Risk Management Standards 2012-2013 Available at: http://www.nhsla.com/NR/rdonlyres/6CBDEB8A-9F39-4A44-B04C-2865FD89C683/0/NHSLARiskManagementStandards201213.pdf (Accessed: 26 May 2012)

PriceWaterhouseCooper (2012) Formal Interventions:  University Hospitals of Morecambe Bay NHS Foundation Trust Governance Review. London: Monitor. Available at: http://www.monitor-nhsft.gov.uk/about-nhs-foundation-trusts/regulatory-action/formal-interventions.  (Accessed: 25 June 2012)

SHALL (2011) Organisational Innovation Submissions http://www.libraryservices.nhs.uk/wiki/Innovations.2011-12-Organisational-Innovations-Submissions.ashx (Accessed 20 June 2012)