Nottingham University
 Hospitals NHS Trust




Outline Business Case Network
  Infrastructure Investment
            Draft...
1. Contents
1 Executive Summary
1.1 Introduction and purpose
1.2 Proposals
1.3 Request for approval


2 Strategic case ove...
5.13 Risk Management Strategy
      5.14 Identification of Risks
      5.15 Risk and Impact Assessment
      5.16 Allocati...
1. Executive Summary

1.1 Introduction and Purpose


Nottingham University Hospitals NHS Trust is currently facing a signi...
and integrated nursecall systems have all been proven to produce significant efficiency
savings as well as the ability to ...
•   Increase the coordination and integration of care across organisational boundaries
    •   Combine clinical teams - to...
Making information more easily accessible is also crucial to generating improvements in
decision making and clinical suppo...
will be a significant transfer of imaging activity from the Trust into the Treatment Centre
including up to 75% of plain f...
Additional support will be sought through these bodies, on a matched funding basis, to help
progress the establishment of ...
3 Economic Case overview
The following section outlines the results of the economic appraisals. A full appraisal of non-
c...
Summary of Economic Appraisals

Cost avoidance


PACS
The recent implementation of PACS across the Trust has increased the...
that ward telephones are often used by patients’ families and friends, blocking their use for
internal communication. Util...
3.2 Benefits Appraisal
  The following table demonstrates the overall service improvement benefits of a programme of
  enh...
Overall Objective                              Service Improvement Objectives

                                −   Reduce ...
    How to maintain "business as usual" while implementing Change with limited
           resources

          Lack of p...
Overall Objective                               Specific SMART Objectives

                              −   Reduce need t...
Cost/benefits analysis

A summary of the costs and return on investment are detailed below;

                        Do mi...
5. Management Case
          5.1 Programme Management Arrangements
The programme, to establish NUH as a Centre of Excellen...
The complexity and scale of the programme may require individual core roles to be provided
         through several indivi...
•   defining service goals
•   establishing frameworks to achieve required objectives
•   making the investment decisions
...
•     establishing and implementing mechanisms by which benefits can be realised and
      measured
•     leading the tran...
5.10Programme Communication Strategy
TBA

5.11Arrangements for Contract Management
TBA

5.12Benefits Realisation Plan


Be...
6 Table of Appendices

Appendix         Description                                 Document Reference
Reference
Appendix ...
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  1. 1. Nottingham University Hospitals NHS Trust Outline Business Case Network Infrastructure Investment Draft 1 October 2006 1 CONFIDENTIAL
  2. 2. 1. Contents 1 Executive Summary 1.1 Introduction and purpose 1.2 Proposals 1.3 Request for approval 2 Strategic case overview 2.1 Local Context 2.2 National context 3 Economic case overview 3.1 Proposed Infrastructure investment 3.2 Benefits appraisal 3.3 Risks 3.4 SMART Analysis of project objectives 4 Financial and commercial case overview 5 Management case overview 5.1 Programme Management Arrangements 5.2 Project Management Arrangements 5.3 Programme Structure 5.4 Responsibilities of the Sponsoring Group 5.5 Responsibilities of the SRO 5.6 Responsibilities of the Programme Manager 5.7 Responsibilities of the Business Change Manager 5.8 Project Board 5.9 Project Plan and Key Milestones 5.10 Programme Communication Strategy 5.11 Arrangements for Contract Management 5.12 Benefits Realisation Plan 2 CONFIDENTIAL
  3. 3. 5.13 Risk Management Strategy 5.14 Identification of Risks 5.15 Risk and Impact Assessment 5.16 Allocation of Risk Ownership 5.17 Monitoring of Risk Management Actions 5.18 Communication with Stakeholders 5.19 Post Project Evaluation 6 Table of Appendices 3 CONFIDENTIAL
  4. 4. 1. Executive Summary 1.1 Introduction and Purpose Nottingham University Hospitals NHS Trust is currently facing a significant financial shortfall and ensuring break even at the end of the 2006/2007 financial year is likely to be a considerable challenge. An initial reduction of 1200 posts has already been identified as a requirement and divisions have been tasked with making savings of 25% over the 3 financial years 2006/2007 to 2008/2009 inclusive. Achievement of these targets will rely heavily on the ability for the Trust to easily introduce changes in working practice, ensuring that essential increases in efficiency, productivity and collaboration can be realised, along with reductions in duplication through centralisation and streamlining of service provision. The current network infrastructure in place across both campuses has grown over a number of years, on a piecemeal basis, with upgrades taking place to provide point solutions based on specific departmental needs. Whilst this infrastructure has adequately supported the operation of the Trust so far, it now presents a serious risk to the Trust’s ability to operate effectively, particularly in relation to the achievement of financial savings, the ability to maximise income, the ability to ensure consistent availability of business critical applications, and the ability to achieve any of the identified savings plans and service redesign initiatives. Between 1 December 2005 and 28 February 2006 there were 27 incidents of network downtime at an approximate efficiency cost to the Trust of over £1.5m. Given that the Trust now has a significantly increased reliance on the availability of newer systems such as PACS, RIS, Pathology, e-Procurement, Theatres and data warehousing solutions the cost and risk of similar downtime in the coming years is likely to be substantially higher. 1.2 Proposals The preferred option to address this issue is an initial Enterprise-wide infrastructure review and replacement covering all core infrastructure components across both existing campuses, along with all local and wide area interconnections linking to the Nottingham Health Community, the wider NHS and the internet. This initial investment will include a full active infrastructure replacement, all associated environmental and cabling requirements, end to end network security management and full wireless network enablement across both campuses, along with the provision of an RFID (Radio Frequency Identification) solution for the Trust. The costs provided also include all project management elements and external services required. The solution will provide the underlying infrastructure required to support the successful delivery of all existing Trust savings plans and service redesign initiatives and will enable more flexibility and adaptability in the way the Trusts services and workforce are delivered. Furthermore, the solution will ensure that business critical data can be made securely available to the right staff at the right time whether working within the Trust, within the wider NHS or externally, including at home. Following the successful completion of the initial phase of this project, additional funding will be required in order to fully exploit the opportunities that healthcare technology can bring and to progress towards the potential establishment of a recognised Centre of Excellence in healthcare technology. Establishment of such a centre will provide significant benefits to NUH, the local community and the wider NHS through the utilisation of leading edge healthcare technologies, the ability to share proven best practice, and the enhanced ability to ensure the best possible outcomes from the healthcare delivered. The use of applications such as RFID, for asset/bed management and tracking, Vocera for mobile communications 4 CONFIDENTIAL
  5. 5. and integrated nursecall systems have all been proven to produce significant efficiency savings as well as the ability to provide genuine improvements in patient care. However, without a suitably designed supporting infrastructure, none of these applications can be successfully deployed and the ability for the Trust to make best use of available technologies is therefore heavily dependent on the successful completion of phase one of the project. The overall benefits of this initial investment towards a Centre of Excellence are highlighted in more detail in the benefits table in section 3.4. 1.3 Request for approval Approval is therefore required for an initial investment of approximately £5m capital and £500,000 revenue over a five year period. This represents the undiscounted costs for the provision of a fully resilient, wireless enabled medical grade network infrastructure. Assuming that future benefits accrue as expected, the return on this investment is expected to amount to approximately £13m over the five year period. Whilst this return alone more than outweighs the required investment, it must also be noted that the achievement of all existing Trust savings plans and targets are also dependent on this infrastructure, and the total savings to be realised therefore could actually be considered to be significantly higher. The initial phase is expected to take approximately 12-18 months to complete. This business case therefore seeks approval from the Nottingham University Hospitals NHS Trust for investment in a wide ranging IT Infrastructure improvement plan, leading to the potential establishment of a Centre of Excellence for technology enabled healthcare. 2 Strategic Case overview 2.1 Local context Nottingham University Hospitals NHS Trust On 1st April 2006, Nottingham City Hospital and Queens Medical Centre, formally merged to form Nottingham University Hospitals NHS Trust. Providing acute services to a local population of over 650,000 and specialist services to a wider population of over two million, the new Trust is now one of the largest in the country. The Trust is closely linked to the University of Nottingham, as a major academic centre, providing teaching to a wide range of health care professionals and has an international reputation for the quality of clinical research undertaken, enabling the Trust to recruit and retain the highest calibre medical staff. Two of the prime aims for the Trust as part of the merger process were; - To improve patient care and outcomes and to sustain service provision across the widest possible range of services - To be in the upper quartile of mergers when compared in terms of financial savings, service rationalisation and financial viability In order to achieve these goals four key objectives were outlined as integral to the Trust’s success criteria; • Capture cost efficiencies – and reduce annual expenditure by 10% of the current combined Trusts’ turnover within three years 5 CONFIDENTIAL
  6. 6. • Increase the coordination and integration of care across organisational boundaries • Combine clinical teams - to deliver more efficient and effective care • Reconfigure service delivery - towards out-patient, day patient and community care. Although reducing operating cost remains a primary driver for the Trust, the related efficiency gains and productivity increases required have also taken on a greatly increased importance. The need for staff to be able to access information from any location, along with the ability for divisions to seamlessly centralise services is therefore paramount in order to maximise the use of increasingly scarce resources. The required (and anticipated) savings will be made considerably more difficult, and in some cases impossible, to achieve without an infrastructure that is fully aligned to these new business goals. Financial position Along with many other NHS Trusts, Nottingham University Hospitals NHS Trust is currently facing a significant financial shortfall and ensuring break even at the end of the 2006/2007 financial year is likely to be a considerable challenge. An initial reduction of 1200 posts has already been identified as a requirement and divisions have been tasked with making savings of 25% over the 3 financial years 2006/2007 to 2008/2009 inclusive. These targets cannot be achieved without the provision of a highly resilient, flexible and scalable underpinning infrastructure, enabling the use of all available technologies. As a result, the Trust will currently be unable to easily introduce changes in working practice, or to ensure that essential increases in efficiency, productivity and collaboration can be realised, along with necessary reductions in duplication through centralisation and streamlining of service provision. The entire savings plan and all associated savings strategies will therefore be severely hampered without the required investment in ICT. Hospital Wide Projects To support the process of reducing costs, a programme of Hospital Wide Projects is being undertaken, along with a number of Service Development Strategies, with a view to reducing the current financial gap through service redesign and associated efficiency savings. However, of the Fifteen projects reviewed, nine have a key outcome of reduced staffing levels, reduced duplication and increased productivity, requiring either the centralisation of a department onto a single site or the use of a single IT system from both sites. A secure and reliable core infrastructure is clearly integral to the successful delivery of these expected benefits. Information and decision making support In addition to supporting financial savings, the availability of accurate and up to date management information is paramount to safeguarding the Trust’s financial position, by maximising income through reliable decision making, support and forecasting. Multiple systems are currently in use across both sites, many of which are ‘stand alone’ with little or no integration between systems. Although local data warehousing systems are currently being implemented, and Connecting for Health solutions anticipated which will provide a more integrated set of management information, the reliability of the basic network infrastructure will be critical to the availability and overall success of these systems. With the advent of Payment By Results, the Trust’s income is, more than ever, dependent on the accuracy, availability and reliability of key management information systems and underlying network infrastructure. 6 CONFIDENTIAL
  7. 7. Making information more easily accessible is also crucial to generating improvements in decision making and clinical support. At present, when a junior clinician seeks the advice of a senior clinician out of hours, the senior clinician usually needs to drive into the hospital. By providing the infrastructure to share data and to collaborate remotely and securely across a ‘virtual private network’, the Trust will save critical time for the patient, improve the quality of life for trust staff by minimising the need for out of hours travel and also reduce the risk and incidence of decisions being made without secondary consultation. The same infrastructure would also eliminate the need for “on call” directors to physically attend the site over the weekend, as is often the case at present. Risks to key hospital systems The Trust now has a vastly increased reliance on a number of key systems in order to operate effectively and the risk of failure of any one, or all of these systems has now become considerable. Not only are there substantial inefficiencies associated with network downtime and re-work required, but there is also serious clinical risk due to the dependence of new clinical information systems on network availability. Recent instances of network failure have provided clear evidence of the severity of this threat, particularly in relation to the systems such as; Pathology, e-Procurement, Theatres, Integra and PACS/RIS. The risk to the Trust when any or all of these systems become unavailable is severe as can by highlighted with the following example which applies to PACS/RIS, with any extended loss of access to PACS from either, or both campuses, resulting in; - Requirement for convoluted workarounds costing significant amount of staff time - Potential need to cancel/rebook appointments due to inability to treat patients through lack of image availability - Significant cost in both instances due to need for data integration at a later date - Substantially increased clinical risk through the potential inability to reconcile images to patients - Significant costs in printing images to film (see Economic Case in section 3) Security With the increased use of (and access to) national applications across the Trust infrastructure, N3 and the internet, the Trust’s business processes are being stretched over ever larger geographies. N3 and national applications have expanded the network in which the Trust operates, and clinicians are increasingly being expected to be linked into the business process 24 hours a day, seven days a week. This significant increase in end-point devices having access to the Trust network at both unpredictable times and locations brings with it a heightened risk from exploits, scams and vulnerabilities such as viruses, worms, Operating System and application vulnerabilities, social engineering and physical intrusion. To meet the requirements generated by these changes in Trust and NHS-wide business processes, the Trust’s underlying network infrastructure needs to become a much more active participant in the Trust’s overall security policy. This can only be achieved by adopting a network infrastructure security model which enables access control of both users and devices, mitigates against malicious software and supports real time interaction between the infrastructure components to self heal and prevent breaches in security. Independent Sector Treatment Centre A major new Independent Sector Diagnosis and Treatment Centre is being planned for development on the QMC site with service delivery commencing late 2007. Given that there 7 CONFIDENTIAL
  8. 8. will be a significant transfer of imaging activity from the Trust into the Treatment Centre including up to 75% of plain film procedures Network connections between the Treatment Centre and the Trust are required as part of this development along with IT interfaces between the Trust and Treatment Centre systems.. PET scanner The newly built imaging centre on the City Hospital campus includes a Positron Emission Tomography scanner, provided by Lister In-Health group which needs to be fully integrated with the Trust PACS, and provide access to electronic ordering, DICOM and the Radiotherapy treatment planning system. Proposals have been submitted to Connecting For Health Information Governance Directorate for agreement of a secure infrastructure interconnection to enable this flow of patient data which in turn, needs to be supported by a secure and robust infrastructure. LIFT Programme The Strategic Service Development Plan for primary and community health and social care services for Greater Nottingham has resulted in a number of new premises being developed, managed by the PCT’s in the Local Health Community over the period 2004-2006. Several major health centres have now been completed with the intention of providing services in situ including dental, plain film and echo cardiology. Remote access is required to and from Trust systems for services such as Radiology in order to report on investigations or provide a secondary opinion, clearly requiring robust and resilient infrastructure links. Nottingham Digital Challenge Nottingham has successfully won through to the top ten in the government’s Digital Challenge competition, a competition aiming to bring technology and communities closer together, the overall winner of which will be awarded £7,000,000 in April 2007 to implement its vision. The Digital Challenge provides a unique incentive for Greater Nottingham to drive forward the use of technologies to better meet the needs of its local community and individual citizens. The ability for the Trust to make early and effective use of the opportunities that this work will present clearly depends on providing the appropriate underlying local infrastructure at the outset. Regional development objectives Both East Midlands Development Agency (EMDA) and Government Office for the East Midlands (GOEM) have clear plans and objectives for funding support in relation improvements in Healthcare through the use of technology. Plans include the urban part of Nottingham and include a cluster strategy covering Healthcare with objectives aimed at realising the benefits of ICT. Specifically, the GOEM plan details the four major areas of activity that companies need to focus on to become more competitive, namely: • Foster an Innovation Culture • Facilitate knowledge and technology transfer • Enable business innovation • Maximise the benefits of ICT 8 CONFIDENTIAL
  9. 9. Additional support will be sought through these bodies, on a matched funding basis, to help progress the establishment of a Centre of Excellence, subject to approval by the Trust to proceed with the project. A copy of the current goem/emda ACTION PLAN IS INCLUDED AT Appendix 6. 2.2 National context Connecting for Health The Connecting for Health programme aims to transform the way the NHS by bringing in modern computer which will improve patient care and services. Over the next ten years, the National Programme for IT will connect over 30,000 GPs in England to almost 300 hospitals and give patients access to their personal health and care information. The Trust has already deployed a number of Connecting for Health applications including; Choose and Book, Picture Archiving and Communications Systems (PACS), Radiology Information System (RIS) and the Emergency Department Information System (EDIS). These will play a critical role in the re-configuration and transformation of service delivery, along with applications due to go live over the next few years such as NHS Care Records Service (CRS), Electronic Transmission of Prescriptions (ETP) have the potential to transform care delivery and to support improvements in overall efficiency. However, to capture the full benefits from implementation of these solutions significant ICT training and network prerequisites must be first be addressed. it will be difficult for the current systems architecture and infrastructure to adequately support improved coordination and integration of care and these factors represent a genuine threat to the Trust’s cost efficiency programme and to the delivery of benefits from the implementation of Connecting for Health solutions. As many of the new applications will be centrally provided, from resilient data centres, the NHS core network has been replaced with the new N3 network to ensure that sufficient bandwidth and resilience is built in to provide reliable and available access. Extremely tight Service Level Agreements have been built in to the service provider contracts in order to ensure that systems and services are available at all times. All infrastructure behind the Trust security boundary remains the local Trust’s responsibility however, the availability and security of information within these new systems has now become a shared risk. It is essential therefore that the Trust is able to match the required levels of reliability and availability and, importantly that the Trust infrastructure can integrate seamlessly with that provided nationally. Connecting for Health currently have no ‘proof of concept’ reference sites where a fully integrated suite of national applications is in use alongside all the additional innovations in healthcare technology. Clearly the establishment of such a centre in Nottingham would be hugely beneficial to the Connecting for Health programme as well as the NHS as a whole. In addition to Connecting for Health, the project already has significant support and resource from a number of industry leading partners both within and outside the NHS, including Cisco, Microsoft and Dell. 9 CONFIDENTIAL
  10. 10. 3 Economic Case overview The following section outlines the results of the economic appraisals. A full appraisal of non- cash-releasing benefits has not been completed, however examples of similar implementations and the efficiency and productivity gains realised have been provided where appropriate. Non-cash releasing benefits in terms of time savings to a range of clinical and non-clinical staff are known to be significant and would amount to tens of millions of pounds. The options evaluated were “do nothing” (continue to purchase tactical infrastructure components as and when immediate needs arise), implement Local Area Network (LAN) upgrades alone, and implement An enhanced LAND infrastructure, replacing all LAN components and providing end to end wireless connectivity and RFID enablement, ultimately leading to the opportunity to establish of a Centre of Excellence in Healthcare Technology. The key assumptions for each option are: Do nothing Assumes that: • Only a minimum piecemeal infrastructure investment is made, as and when needs arise • Service development strategies and hospital wide projects do not currently have specific funding streams in place for infrastructure requirements • service redesign and improvement will continue to take place within the restrictions imposed by the existing infrastructure • Use of, and reliance on critical systems such as PACS, will continue to grow as detailed in the PACS business case • Incidence of network downtime will be the same as the past twelve months and will not increase through use of old hardware. • There will continue to be service-led investment in new digital technologies, e.g. Computed Radiography (CR) and Digital Radiography (DR) within Radiology Strategic Infrastructure upgrade only Assumes that: • investment in Infrastructure is made in line with the costs outlined in Appendix 1 • No enhanced technologies will be required to deliver the service development strategies and hospital wide projects • There will be no requirement to use IP telephony solutions in the first 12 months • Project management will be provided externally • There will be no requirement to purchase an RFID solution in the first 12 months Strategic Infrastructure and strategic service delivery improvement Assumes that: • investment in Infrastructure and associated layer applications is made in line with the costs outlined in Appendix 1, including RFID • Future use of layered applications will be subject to individual business case approval • Funding will be made available to identify more detailed cost savings and develop a full business case • There will be a continued requirement to print 15% of images for departments with no capability to use digital images 10 CONFIDENTIAL
  11. 11. Summary of Economic Appraisals Cost avoidance PACS The recent implementation of PACS across the Trust has increased the clinical dependence on network availability even further, with the tangible costs associated with network downtime even for PACS alone now being significant. Every hour of network downtime now results in nearly 7 hours of rework associated with reconciling orphan studies, along with a potential requirement to print out 200 sheets of film per hour of PACS unavailability. Based on the network downtime experienced over the last twelve months, the cost of downtime in relation to PACS would have amounted to approximately £120,000 of film costs and £42,000 in staff time for the reconciliation required. Details of these costs are attached at Appendix 2. Efficiency gains Productivity increases and efficiency gains have historically been seen as less important when compared with cash releasing benefits. Whilst this is still the case in part, the financial savings plans currently being undertaken, and the likely financial situation over the next two to three years make it more important than ever that the Trust maximises the use of its resources and exploits all available opportunities in service redesign and business process improvement. The use, and guaranteed availability of new technologies will be crucial to ensuring the highest levels of productivity, efficiency and ultimately, patient throughput. The cost to the Trust of network downtime over the last twelve months shows that even prior to the implementation of additional critical systems, considerable efficiency savings and productivity increases can be achieved through the provision of a fully resilient and available infrastructure. Between 1 December 2005 and 28 February 2006, there were 27 unplanned network incidents with a mean duration 6.4 hours. Over the last twelve months, this would have resulted in approximately 103680 hours or 14000 days in lost efficiency, amounting to nearly 63 WTE per year. In financial terms, assuming a conservative estimate of employee costs of £15/hour, this would have resulted in approximately £1.5m in wasted resource. Details of the calculations used to quantify efficiency loss/potential productivity gain are included in Appendix 3. Case studies Where similar healthcare organisations have undertaken a wide scale infrastructure realignment and refresh, significant savings in efficiency have been realised. For example, the Centre d’Hopitalier Montreuil-sur-Mer in France redesigned and reorganised care delivery, automated key processes and implemented a ‘Medical Grade Network’. Productivity increased by 40% - in spite of a 10% reduction in staff and a 20% reduction in the number of beds. Similarly the Sana Hospital in Germany reported cost savings of 20% -achieved through better teamwork and increased productivity, and time and motion studies conducted at the Arras Hospital in France indicated that nurses can spend more than 50% of their time in ‘non- care’ activities: up to 40% in administrative and ‘coordination’ activities and as much as 4 hours per week simply searching for patient records. One reason the proportion of time spent looking for staff is so high is that, frequently, staff cannot contact one another by telephone. The high cost of using patient line terminals means 11 CONFIDENTIAL
  12. 12. that ward telephones are often used by patients’ families and friends, blocking their use for internal communication. Utilising the planned wireless infrastructure, along with new technologies available such as Vocera voice communications, the time spent locating staff can be significantly reduced. Further work will be clearly need to be completed in order to map these potential benefits to the working practices in Nottingham University Hospitals although this will not change the overall ranking of options as a greater value of non-cash releasing benefits will accrue from the enhanced infrastructure option, which is the preferred option overall. Cost savings The Trust now has a significantly increased reliance on the availability of newer systems such as PACS, RIS, Pathology, e-Procurement, Theatres and data warehousing solutions. As a result the cost to the Trust of network downtime has increased dramatically and the associated return on investment timeline for infrastructure spend will be significantly shorter. During the interviews conducted as part of the initial stages of this work several Trust interviewees indicated that as much as 20% of staff time is currently spent searching for equipment or colleagues. This is clearly a major inefficiency and from experiences in other trusts, it is highly likely that there is currently significant ‘over-procurement’ of medical equipment in order to ensure that critically important devices are always ‘locally available’. RFID Accurate, real-time tracking of asset, via a technology such as electronic Radio Frequency Identification (RFID) tags and a full-coverage wireless network would ensure more efficient utilisation of inventory. On an equipment budget of several million pounds such real time ‘location based services’ could deliver very significant cost reductions with potential savings for NUH amounting to some £2m per year (detailed in the spreadsheet at Appendix 4). The same technology could also be used for patient identification and tracking, leading to potentially large increases in patient throughput, along with greatly enhanced, accurate management information on which to base decisions. 3.1 The Proposed Network Infrastructure Investment The preferred option is an initial Enterprise-wide infrastructure review and replacement covering all core infrastructure components across both existing campuses, along with all local and wide area interconnections linking to the Nottingham Health Community, the wider NHS and the internet. This initial investment will include a full active infrastructure replacement, all associated environmental and cabling requirements, end to end network security management and full wireless network enablement across both campuses, along with the provision of an RFID (Radio Frequency Identification) solution for the Trust. The costs provided also include all project management elements and external services required. Full details of the proposed network infrastructure investment are provided in the spreadsheet at Appendix 6. 12 CONFIDENTIAL
  13. 13. 3.2 Benefits Appraisal The following table demonstrates the overall service improvement benefits of a programme of enhanced infrastructure investment. Overall Objective Service Improvement Objectives − Provide accurate, up to date information at the point of care and Improve clinical governance increase patient throughput − Exploit capabilities of new technology and improve ability to respond to change − Increase the percentage of reported images through improved network availability − Reduce repeat clinical procedures because of lost/mislaid images and/or reports − Reduce network downtime and associated need to rebook patients − Improve clinical decision making through making systems and information available for senior clinicians at home/external to the Trust − Reduce time lag in contacting staff out of hours through use of IP based communication solutions such as Vocera − Improve auditing and ability to track assets and equipment − Reduce significant risks, including providing ability to track blood through use of RFID and associated technologies − Reduce risk/incidence of misappropriation of data through security breaches or use of malicious software − Reduce departmental operating costs by minimising requirement for Improve operational cross-town travel effectiveness − Enable real-time bed state reporting and management, enabling safe, accurate financial planning and decision making, increasing throughput and reducing length of stay − Reduce unnecessary referrals through providing secure access to systems and information from primary care − Ensure ill-equipped infrastructure does not compromise ability for Trust to meet savings targets − Reduce staff resource needed to retrieve/deliver notes to wards and clinics. − Reduce nursing staff time in retrieving notes and equipment − Facilitate remote reporting and ‘virtual’ multidisciplinary team meetings through teleconferencing and desktop videoconferencing − Reduce cost of asset tracking, auditing and reduce need to over-order medical equipment, provide real-time view on asset base. − Reduce lead time for healthcare technology implementations through robust, adaptable and flexible infrastructure. − Reduce requirement to re-enter data by providing mobile access to information at point of care − Enable e-prescribing, reducing discharge times and length of stay, increasing speed of bed availability and increasing throughput and income − Reduce number of hospital visits by supporting remote viewing of Improve patient experience images from outreach clinics, radiologist home, other Trusts 13 CONFIDENTIAL
  14. 14. Overall Objective Service Improvement Objectives − Reduce number of admissions and events on the patient journey by providing access to all the information at point of care − Reduce overall patient waiting, e.g. on the ward, in ED by enabling quicker clinical opinion on images and information − Reduce need to duplicate provision of information through enabling information availability at point of care. − Enable secure mobile communications, including patient/visitor access to email/internet from wards etc − Provide wireless hotspots for patient/visitor internet access − Reduce need to rebook appointments/call back for information through significant reduction in network downtime − Enable services/departments to redesign and improve working Improve working environment environment through use of technology and facilities for staff − Increase ability for home working /working external to the Trust − Improve staff morale, recruitment and retention by ensuring distributed access to information allowing for greater collaborative working & improved service − Rationalise use of existing physical storage space through increased electronic access to information − Enable use of teleconferencing and desktop videoconferencing, and reduce requirement for unnecessary travel between sites. − Enhance teaching and research through easier access to information − Enable end-to-end online training provision, improving staff development opportunities and providing greater flexibility in training delivery. − Provide unified messaging facilities enabling staff to look in one place for all personal information. − Enable innovative use and easy early adoption of new healthcare Become a Centre of Excellence technologies, improving ability to respond to change and exploit new for Healthcare technology opportunities − Recruit and retain highest calibre staff through reputation, facilities and technological advances − Gain competitive advantage through enabling most cost effective healthcare provision, along with most successful outcomes, increasing patients, throughput and income − Increase national and international profile and reputation through recognition as a leader in Healthcare Technology 3.3 Risks The clear risks of doing nothing have already been highlighted in preceding sections, however a high level overview of the risks associated with the implementation of an enhanced infrastructure replacement are detailed below;  An overall lack of commitment from IT staff and customers  Insufficient commitment/interest from the Trust senior management 14 CONFIDENTIAL
  15. 15.  How to maintain "business as usual" while implementing Change with limited resources  Lack of planning  Lack of staff skills  Loss of impetus during implementation of the project  No-one accountable for delivery  Expecting major benefits too early  Handover from infrastructure rollout to live operation is not handled effectively  Failure to implement and deliver  Failure of supplier to deliver against specification More detailed risk identification and associated countermeasures are included at Appendix 7. 3.4 SMART Analysis of Project Objectives The overall objectives for the establishment of a Centre of Excellence in Healthcare Technology are summarised under section 3.2 and the specific SMART objectives are summarised below. Overall Objective Specific SMART Objectives − Provide accurate, up to date information at the point of care through Improve clinical governance wireless deployment in all areas of the Trust − Reduce clinical risk by providing ability to tack blood through use of RFID technology − Increase the percentage of reported images through improved network availability − Reduce incidence network downtime to < 0.01 % − Provide access to systems and information available for senior clinicians at home/external to the Trust − Provide desktop video-conferencing in key areas, minimising Improve operational requirement for cross-town travel effectiveness − Reduce unnecessary equipment purchases by 10% through use of RFID − Reduce short term equipment rental requirement by 15% through use of RFID − Reduce annual asset shrinkage rate to less that 2.5% through use of RFID − Reduce staff resource needed to retrieve/deliver notes to wards and clinics. − Enable secure mobile communications, including patient/visitor access Improve patient experience to email/internet from wards etc − Provide wireless hotspots for patient/visitor internet access 15 CONFIDENTIAL
  16. 16. Overall Objective Specific SMART Objectives − Reduce need to rebook appointments/call back for information by reduction network downtime to <0.01% − Provide ability for home working /working external to the Trust Improve working environment and facilities for staff − Enable use of teleconferencing and desktop videoconferencing, and reduce requirement for unnecessary travel between sites. − Provide unified messaging facilities enabling staff to look in one place for all personal information. − Prevent the need for re-work through provision of 99.99% network availability 4 Financial and Commercial Case summary Costs A summary of the proposed infrastructure investment is included in the table below. Full costed details are included in Appendix 1. PROJECT ELEMENT PRICE Discovery, Site Survey, Audit & Documentation £140,000 Environment - UPS Systems, Air Con. Etc £200,000 Cabling -passive infrastructure £400,000 QMC LAN £1,109,097 NCH LAN £699,901 VPN £50,338 Wireless LAN £861,058 RFID £420,000 Business Protection £352,608 Training £56,700 Project Management £511,000 On-site Support Spares £30,147 SUB TOTAL £4,830,849 10% Contingency £483,084.9 TOTAL £5,313,934 16 CONFIDENTIAL
  17. 17. Cost/benefits analysis A summary of the costs and return on investment are detailed below; Do minimum Infrastructure investment only Enhanced Infrastructure investment Cost (£'000) Cost (£'000) Cost (£'000) Capital 1,000 4,200 5,500 Recurrent 250 450 560 Total cost 1,250 4,650 6,060 Cash releasing Non-cash releasing Cash releasing Non-cash Cash releasing Non-cash benefit (£'000) benefit (£'000) benefit (£'000) releasing benefit benefit (£'000) releasing benefit Productivity improvement through improved reliability 0 0 0 7,775 0 7,775 PACS re-work 0 0 0 210 210 PACS film 0 0 590 0 590 0 RFID asset tracking - maintenance staff time 0 0 0 0 0 1,250 RFID asset tracking - clinical staff time 0 0 0 0 0 4,375 RFID - equipment saving 0 0 0 0 4,640 Total savings 0 0 590 7985 5230 13610 Cost net of cash releasing benefits 1,250 4,060 830 Equivalent net cost less non-cash releasing savings 1,250 -3,925 -12,780 17 CONFIDENTIAL
  18. 18. 5. Management Case 5.1 Programme Management Arrangements The programme, to establish NUH as a Centre of Excellence (CoE) for the use of ICT in Healthcare requires a Programme Management framework to ensure that the portfolio of projects and their associated benefits are delivered and the desired outcomes of the programme are achieved. This management approach will follow OGC guidance 1 and is adopted because the nature of the programme requires not only the deployment of vital ICT enablers, comprising IT infrastructure , software applications and systems, but also the delivery of a significant overarching change management agenda to ensure that benefits are achieved from the investment. Key criteria which characterise the programme are: • Complex and large-scale changes across specialties, divisions, and campuses necessary to achieve successful outcomes • Exploitation of the many commonalities between projects within the portfolio and management of their interdependencies • Best use of scarce resources and skills which will require the programme to establish clear priorities with a focus on those projects and activities that will deliver the strategic objectives • Firm management throughout the life of the programme in a changing environment, both internally and externally imposed. • Benefits to be realised early as each project within the portfolio is delivered • Ownership of a high degree of risk 5.2 Project Management Arrangements Individual projects comprising the programme will be managed according to PRINCE2. The details of the programme organisational structure are set out in the following diagram. The membership and terms of reference for key roles and teams are described below. 5.3 Programme Structure The structure below aims to ensure appropriate engagement between individual projects comprising the portfolio and the team responsible for sponsoring the programme. The scope of each of the projects is likely to require a dedicated project manager, delivery team and possibly Board. However, it may be beneficial to establish a single Project Board (including an SRO), to eliminate the need for individual Project Boards. 1 “Managing Successful Programmes”, 2004 18 CONFIDENTIAL
  19. 19. The complexity and scale of the programme may require individual core roles to be provided through several individuals. For example the programme manager may require support in the form of a risk manager, procurement lead and technical design authority SPONSORING GROUP (Core Programme Roles) Senior Business Programme Responsible Change Manager Owner Manager Project Board Project Board Project Board “CENTRE OF EXCELLENCE” PORTFOLIO Project Project Project Project A Project B Project C etc Manager Manager Manager Project Project Project Delivery Team Delivery Team Delivery Team 5.4 Responsibilities of the Sponsoring Group The group is made up of senior managers responsible for: • championing change management 19 CONFIDENTIAL
  20. 20. • defining service goals • establishing frameworks to achieve required objectives • making the investment decisions 5.5 Responsibilties of the SRO • owning and championing the programme vision • securing the investment necessary to deliver the programme and transitional activities • providing overall direction, leadership and accountability for the success of the programme • programme governance including financial and quality aspects • programme brief and business case and other key information • ensuring effective communications and interfacing with key senior stakeholders • managing key strategic programme risks • maintaining alignment of the programme with the Trust’s strategic direction • ensuring that the Trust and its staff are managed carefully through the process of change • commissioning and chairing reviews throughout the programme lifecycle to assess continued alignment with objectives, capability to deliver, and measurable achievement of benefits • managing and supporting the programme manager 5.6 Responsibilities of the Programme Manager • planning and designing the programme delivery and proactively monitoring progress and initiating appropriate correcting action • defining the programme governance framework • ensuring the integrity of the programme both internally and externally • managing the programme budget and monitoring expenditure and costs against benefits realised • ensuring project outputs/products are delivered within time, cost and quality tolerances and comply with governance arrangements • ensuring maximum efficiency in the allocation of resources and skills • managing third party contributions, e.g. external suppliers • managing stakeholder communications • managing programme risks and inter-project dependencies • intervening appropriately wherever gaps arise in the programme or issues arise • reporting progress in programme delivery to the SRO at regular intervals 5.7 Responsibilities of the Business Change Manager • ensuring the interests of the sponsoring group are met by the programme • obtaining assurance that the delivery of new capability is compatible with realisation of benefits • working with the programme manager to ensure that the scope of the portfolio and constituent projects provides the products necessary to enable operational benefits to be realised • working with the programme manager to identify projects that will contribute to realising benefits • identifying, defining and tracking the required benefits and outcomes • identifying and implementing the maximum improvements in business operations as project products come on stream • managing the realisation and accrual of benefits throughout the programme lifecycle and after completion 20 CONFIDENTIAL
  21. 21. • establishing and implementing mechanisms by which benefits can be realised and measured • leading the transition management and preparing the ground for new business processes • optimising the timing of project deliverables into operations 5.8 Project Board Directs the project and has responsibilities for: • project Initiation • approving overall organisation structure and plans • monitoring and control of progress against agreed tolerances • problem referral • project Closure 5.9 Project Plan and Key Milestones An outline implementation plan is included in Appendix xxx. The key milestones are summarised in table xxx below: Table 7. Programme Milestones Ref Milestone Description Target Date 1 Prepare Outline Business Case for Centre of August – September 2006 Excellence Programme 2 Secure Trust Board approval to proceed to October 2006 FBC for phase 1 – the MGN 3 Convene Sponsoring group and appoint SRO and Programme and Business Change Managers 4 Secure funding for phase 1 MGN 5 Confirm portfolio to achieve Centre of Excellence outcomes 6 Procure supplier for MGN 7 Phased Implementation of MGN 8 Deliver phase 2 project(s) 9 Deliver phase 3 project(s) 10 Etc.... 11 Complete programme & confirm closure 21 CONFIDENTIAL
  22. 22. 5.10Programme Communication Strategy TBA 5.11Arrangements for Contract Management TBA 5.12Benefits Realisation Plan Benefit profiles and a benefits realisation plan will be derived from the programme Blueprint which describes the “to be” service model for NUH and is based on the vision statement for the Centre of Excellence programme. This is summarised in the desired outcomes for a ‘Connected Hospital’ as follows: • Enterprise wide information and systems architecture with high levels of process standardisation, data standardisation, and systems integration • Fully deployed advanced clinical information systems to support core organisational processes including: - order entry - clinical decision support systems, e.g. medicines management - picture archiving and communications (PACS) - digital health care records accessed via Notis - etc.... need to extend list • Controlled access at the point of need to patient data including images • Management Information Systems which generate key performance and compliance metrics based on real-time data captured from Trust operational systems • External connectivity to provide online services to PCTs, Independent Healthcare providers and direct to patients • ‘Pervasive’ security – for both physical assets and sensitive data • A standardised high performance network that supports data, voice, video and mobile working 5.13Risk Management Strategy 5.13.1 Identification of Risks 5.13.2 Risk and Impact Assessment 5.13.3 Allocation of Risk Ownership 5.13.4 Monitoring of Risk Management Actions 5.13.5 Communication with Stakeholders 5.14Post Project Evaluation 22 CONFIDENTIAL
  23. 23. 6 Table of Appendices Appendix Description Document Reference Reference Appendix 1 Itemised solution costs C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix Appendix 2 Network unavailability - PACS costs C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix Appendix 3 Network unavailability – efficiency costs C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix Appendix 4 RFID cost savings C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix Appendix 5 Overall project cost/benefits analysis summary C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix Appendix 6 Government Office for East Midlands/EMDA action plans C:Documents and C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix SettingsismithDesktopMergerCisco s Appendix 7 Risk assessment summaries C:Documents and SettingsismithDesktopMergerCisco studiesOBCAppendix 23 CONFIDENTIAL

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