briefing note template - heart of england nhs … · web viewthe current system for chemotherapy...

INVESTMENT APPROVAL BRIEFING TO: Group 2 Directorate: Oncology/Haematology/PharmacyProject Ref: P.Sponsor: P. Lead: Dr Guy Pratt/Gaynor Hill

1. EXECUTIVE SUMMARYDECISION REQUIRED Justification Case Approval / Endorsement GATE 1

INVESTMENT DRIVER(S) PROPOSAL SCOPE

Patient safety / Prescription and administration error avoidance – clear legible prescriptions for chemotherapy with decision support and assistance for dose calculations. Improved communication in the pharmacy ordering process. Improved patient waiting times for outpatient prescriptions and continuous track of previous medications. Capture of contracting and cancer intelligence information.

Inpatient and Outpatient prescribing of chemotherapy by the oncology and haematology directorate at Solihull, Heartlands and Good Hope. Procurement and implementation over 9 months following funding approval. Full time project management.

BENEFITS / FIT TO STRATEGY

Improved clinical Governance Support accurate HRG reporting

Meet regional strategy (Pan Birmingham Cancer Network)

Compliance with National Chemotherapy Advisory Group Report

FORECAST FINANCIAL IMPACT £k* PYE 08/09 FYE 09/10 FYE 10/11 FYE 11/12 TotalInitial Capital to Delivery 215,640Company set up costs 73,320

Pharmacy recurrent staffing costs 174,216 174,216 174,216IT recurrent staffing costs 91,000 91,000 91,000

Gross Initial InvestmentGrants/external funding (+ source)Net Initial InvestmentMarginal cost/savings excl dep’nMarginal incomeTotal Cash Flow impactImpact on Trust Surplus 0 0 554,176 265,216 265,216

Proposed Funding SourceInitial Investment Quality Central Costs to next

Gate X £xkOngoing Business Unit

Project Life xyrs FYE Pay £xk NPV £xk Drivers Matrix xxxPrior

approvalNA?

Cap £xkFYE Drugs £xk Payback X mths Delivery

Rev £xk

Drivers for investment

The implementation of an oncology e-prescribing system will help meet challenges faced by the Trust and will support the trust meeting the following objectives:-

To meet a National Cancer Standard. Without e-prescribing we will fail Peer Review for chemotherapy.

To utilise e-prescribing so as to make efficient use of the clinical and administrative resources. To use the planning and decision support tools of the system to simplify the management of clinical

complexity.

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To use electronic protocols and regimens in order to minimise clinical risk. To have a comprehensive audit facility to improve patient safety. To improve safety To enable NICE guidelines to become an inherent part of clinical practice. To meet the cancer waiting times targets and service improvement as defined by the Department of

Health. To utilise scheduling tools in order to allow the optimisation of resources and booking of

appointments. To track and report on high cost drug usage and chemotherapy contracting. To report the chemotherapy dataset to the NCIN. To reduce the risk of medication errors by nursing staff around clarity of prescriptions.

Based on the above assessment of drivers, needs and the current position, the following investment aims have been defined for the proposed oncology prescribing investment:-

To reduce waiting times To improve patient safety To reduce drug wastage To reduce drug cost Improve tracking and reporting of high cost drugs usage.

The following table presents a series of specific objectives that have been set against each aim.

Aim Associated ‘SMART’ Objectives

Reduce waiting times Meet 31 and 62 day cancer waiting time targets for 100% of patients where first treatment is chemotherapy

Improve patient safety To reduce prescribing errors by 5% on 2005/06 figures

Prevent avoidable deaths

Human error kept to a minimum by reducing the number of staff involved in checking and reducing the total number of checks required

Stop clinical staff being involved in note pulling and therefore release their clinical time for patient care and administration

Safe prescription checking and administration of blood products

Reduce drug wastage Improved scheduling of patients

Access to patient blood results

Support the unit’s efficiency drives to reduce drug wastage by 0.5%

Reduce drug cost Protocol based prescribing

Transparency of agreed protocols to enable improved contracting of drug prices

Improve tracking and reporting of High Cost Drugs

Ability to monitor total spend on cancer drugs by HRG and thus inform payment by results calculations

There is clear need, support and commitment for the implementation of a software solution to

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support electronic chemotherapy prescribing to improve patient safety and quality.

Electronic prescribing has a demonstrable impact upon prescribing errors. The recent safety data audited by UCLH indicated a 45% reduction in the level of catastrophic and major errors after the implementation of a specialist chemotherapy prescribing system.

Electronic prescribing is an expected standard for chemotherapy prescribing as indicated by it being a National Cancer Standard measure which currently we fail..

The current system for chemotherapy using pre-printed prescription proformas does not provide decision support. Although space to prompt for lab results and information to support dose calculation is provided the system is unable to mandate their use and prescribing errors result. The system relies on an additional manual check by pharmacy staff to intercept these errors before they reach the patient.

The electronic prescribing system in use across the rest of the Trust is not designed to deal with the complex scheduling, infusion regimens and specific special considerations of this speciality.

Moreover it does not give the option to prescribe IV fluids and blood products which are crucial for most of the Haematology/Oncology patients thus putting more pressure to the delivery of care to the patient

Electronic chemotherapy prescribing systems facilitate both prospective and retrospective audit at all levels. The adoption of common, structured, disease based protocol driven prescribing ensures patients are offered the most appropriate and equitable treatments.

Electronic chemotherapy prescribing supports Health Related Groups (HRG) reporting, providing a high level of accuracy and thus ensures that the correct level funding is secured for the oncology service to accurately finance the activity being provided and it also permits automatic recording of chemotherapy activity required by the NCIN..

The purchase of an electronic chemotherapy prescribing system will improve standards of clinical governance and facilitate risk management by providing a fully auditable record of all chemotherapy prescribed and administered. Accurate documentation of clinical and pharmacy workload and appointment scheduling may facilitate the achievement of performance targets, e.g. the Booked Admissions Programme.

The implementation of an electronic chemotherapy prescribing system is viewed as part of the Pan Birmingham Cancer Network’s overall strategy to integrate the clinical systems into a whole care record; this option has the potential for integration into the national Integrated Care Record Service.

The proposed procurement route is via OJEU tender. Full time project management and ongoing support would be required. A robust and maintained infrastructure (e.g. wireless network) and access to computer hardware (e.g. mobile computer devices) will be vital to the success of the project.

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Expected Project Benefits

The following list outlines the additional specific benefits for chemotherapy:

Eliminate the need for paper based chemotherapy protocols by establishing a central repository of protocols and regimes accessible by all relevant staff at the point of need which reduces time writing prescriptions;

Computer printouts make the prescriptions legible; on the other hand if the EP system supports a remote tablet form across the Haemato-oncology Unit computer printouts might not be necessary at all

An automatic interface to the patient’s hospital record. This will eliminate duplicate work to write out patient details every time a prescription is made;

Improved retrieval of patient information;

Opportunity to audit all chemotherapy prescriptions including the audit of NICE drugs and reduce drug wastage;

Integrating working practices and support of multi-location treatment;

Improve management and audit data;

Monitor side effects and outcomes to treatments;

Reduce risk of prescription and preparation errors;

Enable Haematology and Oncology SpR trainees to increase their confidence in chemotherapy prescribing

Enable Trusts to inform commissioners of chemotherapy activity and drug costs so that effective use of resources and accurate coding of OPCS\HRG codes as planned by the Department of Health.

Automatic recording of chemotherapy delivery to the NCIN

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INVESTMENT APPROVAL BRIEFING TO: Group 2 July 2011Directorate: Oncology/Haematology/PharmacyProject Ref: P.Sponsor: P. Lead: Dr Guy Pratt

2. BENEFITS REALISATION REVIEW PLANTitle of Business Case: Electronic Chemotherapy Prescribing Review Dates Due CompletedBusiness Case Reference No: Overall Project Lead Dr G Pratt First Review: (after

implementation) +3 monthsBusiness Unit: Group 2 and 4 Operations Director Sarah Rose Second Review: +9 monthsDirectorate: Oncology/Haematology/

Pharmacy Clinical Director: Dr J Ewing Subsequent Reviews: Annual

Directorate Accountant: Richard Barratt Project Manager: Estates/ICT TBC

Agreed current prices Actual Variance Reasons for VarianceInitial Investment (£k) 554,176 554,176 4554,176 Full funding required

Revenue Cost Base Increase (£k)

Revenue Savings Impact (£k)**

Income Impact (£k)Contribution (£k)

Implementation DateJanuary 2013

Project outline scope:*Costs savings positive, cost increases negative. Income impacts: increase positive, decrease negative **Show savings separately from impact on cost base

Ref Critical Success Factors & link to KPI. Benefit Type

Key Measures (KIM)

Base Value

Target Value

Target Date Review Status Comments / Actions

Agreed

C1Implementation of electronic chemotherapy prescribing at SH, BHH and GH (inpatient and outpatient)

Chemotherapy prescribed

electronically0% 100%

C2 Link to Pathology results Automatically

filled on prescription

0% 100%

C3 Reduction in prescribing calculation or regimen errors detected by pharmacy

Reduction of error rate 0% 100%

C4Reduction in pathology results related errors detected by pharmacy

Reduction of error rate 0% 100%

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Ref Additional Success Factors/Benefits to be Achieved & link to KPI.

Benefit Type KIM Base

ValueTarget Value

Target Date Review Status Comments / Actions

Agreed

A1Automated collection of data for:

HRG costingCancer Minimum Data Sets

Reduction in additional data

entry0% 100%

Overall Status Comment: Where not green or ‘grey area’ summarise issues which have defined status eg. ‘Delayed recruitment , risk to LOS’ Investment Team Lead: Name

Key Review status Key : Red – Delivery at risk and mitigating actions ineffective. Amber – Delivery at risk, mitigating actions agreed. Green Delivery not at risk.

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BUSINESS CASE: CONTENTST*

Page No.

1. Executive Summary 12. Project Benefits Realisation Review Plan ‘BRRP’ 3

3. Summary and Recommendations 54. The Case for Change 5

APPENDICESA. The Strategic Context 7B1: Current Risk Assessment Matrix 8B2: Project Drivers Matrix Score 9C. Option Appraisal Summary 10D. Option Appraisal 11E. Initial Investment Analysis 13

3. SUMMARY AND RECOMMENDATIONS

The other options – do nothing, employ additional resource to better maintain the paper system – do not, or do not fully, address the risks in the current system

The approving body is asked to agree to proceed to full business case.

4. THE CASE FOR CHANGE

The current system for chemotherapy using pre-printed prescription proformas does not provide decision support. Although space to prompt for lab results and information to support dose calculation is provided the paper is unable to mandate their use and prescribing errors result. The system relies on an additional manual check by pharmacy staff to catch these errors before they reach the patient. In addition the complexity and number of cancer treatment regimens continues to increase putting further pressure on this system and the team maintaining the pre-printed proformas.

The management of aseptic dispensing in the pharmacy aseptic unit is managed manually. The management of this work is key to the flow of patients in the treatment areas. Delays in communication can cause delays to treatment and clinics to overrun making patients dissatisfied about the level of service they receive and putting additional pressure to the nursing, medical, pharmacy and managerial staff.

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The electronic prescribing system in use across the rest of the Trust is not designed to deal with the complex scheduling, infusion regimens and specific special considerations of this speciality. In addition it doesn’t provide the option of IV fluids and safe blood product prescribing which is crucial for patients receiving chemotherapy

Electronic prescribing for chemotherapy is part of the Pan Birmingham Cancer Network Strategy and has been supported by Lord Warner’s ministerial commitment to the widespread deployment of solutions across all cancer networks. It will also support the multidisciplinary team meet the aims of the NHS Cancer Plan (2000).

It is assumed that the benefits realised at other Trusts can be emulated at HEFT. The primary benefits expected to be achieved are an improvement in patient safety and improvement in the management of treatment preparation and delivery.

The project is dependent on the Trust’s ICT infrastructure and robust network provision.

Indicative way forward

The proposed next step is to develop a detailed specification and to tender a contract through the OJEU process for an electronic chemotherapy prescribing system.

The other options – do nothing, employ additional resource to better maintain the paper system – do not, or do not fully, address the risks in the current system.

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APPENDIX A: THE STRATEGIC CONTEXT

The implementation of electronic prescribing for chemotherapy will drive up quality of care for patients and remove the inherent risks of dosing errors. This is clearly one of the requirements laid out in NCAG and in the directorate strategy as a must do. The National Chemotherapy Advisory Group Report “Chemotherapy in England: Ensuring Quality and Safety” and the Cancer Reform Strategy have clearly identified DH expectations that competent providers of chemotherapy will quickly move to electronic prescribing and that competent commissioners of cancer care will expect this of their providers. There are two key drivers. The first is to improve safety in treating patients with chemotherapy. There is good evidence that e prescribing reduces prescription errors and provides much better, easily available, information on previous therapy and cumulative doses. Secondly, it will become critical to have accessible information on treatment regimens. These will be needed for accurate contracting information when chemotherapy moves into tariff and to improve the information available to the NCIN for better quality data on clinical outcomes demanded by the Coalition White paper.

Organisational or Departmental Overview

The current system for chemotherapy using pre-printed prescription proformas does not provide decision support. Although space to prompt for lab results and information to support dose calculation is provided the paper is unable to mandate their use and prescribing errors result. The system relies on an additional manual check by pharmacy staff to catch these errors before they reach the patient. In addition the complexity and number of cancer treatment regimens continues to increase putting further pressure on this system and the team maintaining the pre-printed proformas.

The management of aseptic dispensing in the pharmacy aseptic unit is managed manually. The management of this work is key to the flow of patients in the treatment areas. Delays in communication can cause delays to treatment and clinics to overrun.

The chemotherapy prescribing system is capable of interfacing with Trust systems, especially the PAS and Pathology systems.

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Oncology and Haematology Activity – April 2010 – March 2011

Inpatient AttendancesActivity - 1st April 2010 to 31st March 2011

Inpatient Activity by Patient Spells

Daycase Elective Emergency TotalGood Hope 0Clinical Haematology 2,266 8 2 2,276Medical Oncology 3,559 6 4 3,569Oncology 0Heartlands 0Clinical Haematology 4,942 359 228 5,529Medical Oncology 1 1Oncology 3,962 169 53 4,184Solihull 0Oncology 240 1 241Total 14,970 543 287 15,800

Outpatient Activity (ward attenders excluded)

Good Hope Heartlands Solihull TotalFirst attendance

Haematology Anti-Coagulant 866 725 397 1,988Haematology Clinical 401 1,556 224 2,181Medical Oncology 612 263 875Oncology 147 922 255 1,324

First telephone or telemedicine consultation

Haematology Anti-Coagulant 1 1Haematology Clinical 2 63 65Oncology 72 257 76 405

Follow-up attendance Haematology Anti-Coagulant 18,910 16,320 8,112 43,342Haematology Clinical 3,370 8,074 30 11,474Medical Oncology 4,532 1,341 5,873Oncology 27 4,495 1,732 6,254

Follow-up telephone or telemedicine consultation

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Haematology Anti-Coagulant 2 1 3Haematology Clinical 36 136 172Medical Oncology 2 2Oncology 134 1,426 185 1,745Total 29,114 35,579 11,011 75,704

Daycase

Specialty Site DaycasesHaematology Clinical Good Hope 2266Haematology Clinical Heartlands 4942Medical Oncology Good Hope 3559Medical Oncology Heartlands 1Oncology Heartlands 3962Oncology Solihull 240

Business Strategies

The purchase of the chemotherapy prescribing system will improve standards of clinical governance and facilitate risk management by providing a fully auditable record of all chemotherapy prescribed and administered. Accurate documentation of clinical and pharmacy workload and appointment scheduling may facilitate the achievement of performance targets, e.g. the Booked Admissions Programme. Furthermore, the data stored by the system may, in the future, allow improved documentation of chemotherapy costs to defined purchasing organisations, and hence be of considerable benefit to the Cancer Network.

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Other Organisational Strategies

The benefits of implementing electronic chemotherapy prescribing have been long understood and have been supported by Lord Warner’s ministerial commitment to the widespread deployment of solutions across all cancer networks.

The cancer action team (CAT), in collaboration with NHS Connecting for Health (CfH) and Professor Mike Richards has been keen to ensure that cancer networks implement appropriate and compliant electronic systems.

The implementation of a chemotherapy prescribing system is viewed as part of the Pan Birmingham Cancer Network’s overall strategy; this option has the potential for integration into the national Integrated Care Record Service.

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APPENDIX B1: CURRENT RISK ASSESSMENT MATRIX

Table 1 – MEASUREMENT OF LIKELIHOOD

Level Descriptor Description0 Never The event cannot happen under any circumstances1 Rare The incident may occur only in exceptional circumstances2 Unlikely The incident is not expected to happen but may occur in some circumstances3 Possible The incident may happen occasionally4 Likely The incident is likely to occur, but is not a persistent issue5 Almost Certain The incident will probably occur on many occasions and is a persistent issue

Table 2 – MEASUREMENT OF CONSEQUENCE

Level Descriptor Description0 None No injury or adverse outcome. Low financial loss1 Insignificant No injury or adverse outcome; First aid treatment; Low financial loss

2 Minor Short term injury/damage (e.g. resolves in a month); a number of people are involved

3 Moderate Semi permanent injury (e.g. takes up to year to resolve)

4 Major Permanent injury; major defects in plant, equipment, drugs or devises; the incident or individual involved may have a high media profile

5 Catastrophic Death

Table 3 - ASSESSMENT MATRIX THE RISK FACTOR = LIKELIHOOD X CONSEQUENCE

CONSEQUENCE

LIKELIHOOD None0

Insignificant1

Minor2

Moderate3

Major4

Catastrophic5

0 Never 0 0 0 0 0 01 Rare 0 1 2 3 4 52 Unlikely 0 2 4 6 8 103 Possible 0 3 6 9 12 154 Likely 0 4 8 12 16 205 Almost Certain 0 5 10 15 20 25

By using the matrix above the risk score can be calculated to determine risk category. This ranges ranging from 1 (low severity and unlikely to happen) to 25 (just waiting to happen with disastrous and widespread consequences). The risk score can now form a basis upon which to determine the urgency of any actions. *Risks which have a priority score of 9 or more should be reviewed by the Directorate Management Team immediately. Green status denotes low risk. Yellow can denote moderate to Significant risk. Red risks which score 15 or more must be notified to the Risk Register Officer.

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APPENDIX B2: PROJECT DRIVERS SCORE MATRIX

SCORE

RISK AVOIDANCE

(i.e. CURRENT RISK OF DOING NOTHING) (25%)

IMPROVEMENT TO PATIENT CARE (25%)

FIT WITH MISSION/STRATEGY

(25%)

IMPACT ON MARKET

SHARE (10%)FINANCIAL

VIABILITY (15%)

5

Very high risk score (> 20) as per Trust’s Risk

Assessment Matrix

Clear evidence that the case

delivers a specific & tangible

improvement to patient care

Clear evidence that the case delivers a specific & tangible

element of the Trust’s Strategy

Growth in Market share is real, sustainable,

increases income & is

agreed with the Trust’s key

stakeholders

Revenue Surplus/ Prevention of Lost Revenue > £500k

&/or Pay back period < 3 years AND NPV

+ve

4

High risk score (15 to 19) as per

Trust’s Risk Assessment

Matrix


directly drives a specific & tangible

improvement in patient care

Clear evidence that the case directly

drives a specific & tangible element of the Trust’s Strategy

Case identifies real potential for

future sustainable increases in

income & Market share

Revenue surplus £251k to £500k &/or Pay Back period < 4 years AND NPV +ve

3

Medium risk score (9 to 14) as per Trust’s Risk

Assessment Matrix


directly drives the Strategy on

improving patient care

Clear evidence that the case directly

drives the delivery of the Trust’s Strategy &

Mission

Case directly influences other opportunities for future growth in

income & Market share

Revenue surplus £101k to £250k &/or Pay Back period < 5 years AND NPV +ve

2

Moderate risk score (4 to 8) as per Trust’s Risk

Assessment Matrix

Evidence that the case

influences a specific part of the Strategy on

improving patient care

Evidence that the case influences a specific

part of supports the wider delivery of the Trust’s Strategy &

Mission

Case is needed to maintain our current market share & income

Revenue surplus £0 to £100k &/or Pay

back period < 5 years AND NPV +ve

1

Low risk score (1 to 3) as per Trust’s Risk Assessment

Matrix

Evidence that the case

influences improvements in

patient care

Evidence that the case influences the

delivery of the Trust’s Strategy & Mission

No impact on market share &

income

No revenue implications – cost neutral AND NPV

+ve

0 No risk, score 0No impact on patient care

improvements

No impact on delivering the Trust’s Strategy & Mission

Reduces market share & income

Net revenue loss and/or NPV –ve

SCORE Eg. 4 Eg. 3 Eg. 3 Eg. 1 Eg.2

WEIGHTING 4 x 25 = 100 3 x 25 = 75 3 x 25 = 75 1 x 10 = 10 2 x 15 = 30

WEIGHTED SCORE 290

.

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Option Appraisal

Baseline Option – Do nothing

The current system of prescription proformas for individual treatment regimens fails to deliver a sufficiently consistent safe service to patients. The forms are able to prompt clinicians to check the appropriate results and make the appropriate dose calculations – but these actions must be manually completed and cannot be mandated which introduces the possibility for human error.

Current staff resources have not allowed the prescription proformas to be kept up to date and this further exacerbates the risks presented by this option. In some cases prescribers using out of date proformas are required to make manual amendments to the prescription and, as such, the benefits of the proforma are negated.

Baseline Option Risk Assessment

Description of risk: Inappropriate dose or scheduling of dose is prescribed due to miscalculation by the prescriber, omission of lab results check, or poorly laid out proforma.

Possible consequence: Major/Catastrophic (4/5)Likelyhood: Possible (3)Score: 12 - 15

Project Drivers Score

No change – not applicable

The baseline option IS NOT the preferred option.

Option 1 – Invest in current system – Paper based prescribing

An additional junior pharmacist to release more senior pharmacist time would allow the current system to be properly maintained. This would eliminate the risks associated with manual amendments to the pre-printed prescription forms.

Suggested resource: 1.0 WTE x Band 6 pharmacist

The problems associated with manual calculations and results checks would still persist.

Option 1 Risk Assessment

Description of risk: Inappropriate dose or scheduling of dose is prescribed due to miscalculation by the prescriber or omission of lab results check.

Possible consequence: Major/Catastrophic (4/5)Likelihood: Unlikely (2)Score: 8 - 10

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Score Weight Weighted ScoreRisk: 3 25 75Improvement to patient care: 2 25 50Fit with mission / strategy: 2 25 50Impact on market: 2 10 20Financial viability: 2 15 30

Total 225

Option 1 IS NOT the preferred option.

Option 2 – Electronic chemotherapy prescribing

The purchase of an electronic chemotherapy prescribing system will improve standards of clinical governance and facilitate risk management by providing a fully auditable record of all chemotherapy prescribed and administered. Accurate documentation of clinical and pharmacy workload and appointment scheduling may facilitate the achievement of performance targets, e.g. the Booked Admissions Programme.

The system will integrate with the Trusts existing results reporting and PAS systems to provide process and clinical decision support (e.g. no go ahead without blood results as well as dose reduction recommendations).

Option 2 Risk Assessment

Description of risk: Inappropriate dose or scheduling of dose is prescribed due to miscalculation by the prescriber or omission of lab results check.

Possible consequence: Major/Catastrophic (4/5)Likelihood: Never/Rare (0/1)Score: 0 - 5


Score Weight Weighted ScoreRisk: 2 25 50Improvement to patient care: 5 25 125Fit with mission / strategy: 5 25 125Impact on market: 5 10 50Financial viability: 0 15 0

Total 350

Option 2 IS the preferred optio

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briefing note template - heart of england nhs … · web viewthe current system for chemotherapy...

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